Hi everyone and welcome to this webinar on setting standards in chronic pain management. So today I'm gonna talk through some ideas with you to give you some structure to your pain management consultations. I think there are a variety of resources available, certainly if we're talking about the management of osteoarthritis.
And we will use the management of osteoarthritis as an example to give us a structure for then moving into managing other types of pain. But there are a variety of resources out there and guidelines on how to manage arthritis. What we'll then do is think about translating those guidelines into managing something like neuropathic pain, other types of chronic pain, for example, spinal pain.
So rather than just thinking, well, spinal pain, it's neuropathic pain, reaching for the gabapentin and taking a let see approach, we can be a little bit more structured about how we approach this. There's gonna be plenty for you to think about, and there is gonna be some work required on your part and on the practise part to make this work, but it's worth it. It will improve everyone's job satisfaction, it will help to improve your client outcomes, and it should generate some revenue for your practise as well.
So we're gonna look at standards in pain assessment, the approach to practise you take, and little tips on owner approaches and how introducing those standards and pain assessment can help with how our owners approach management of their pets, chronic pain, making them, getting them on board. So this diagram here, the multimodal management of pain, this is how I think about managing pain, particularly osteoarthritis, and like I say, I translate this to a different situation. So the correct non-steroidal, and you've heard me talk about this before, we need to find a non-steroidal that suits the patient that the owner can can administer to the patient.
And we'll come back to the importance of non-steroidals. Weight control, diet and exercise, these are all relevant in all types of chronic pain management. What we're doing is we're managing the pain, but we're also managing the patient's quality of life.
So exercise does become really important. And you'll hear owners say this, that, oh, when, when he doesn't want to go for a walk, but when he does go for a walk, he's much more interactive, he's a much happier dog. And we know that when owners can exercise their pets, ratings improve on those health related quality of life scales.
We're going to talk about pain scores and the importance of pain scoring, and really I think pain scoring is the absolute baseline to managing pain in these patients, and I hope to show you why. We're gonna talk about pain indicators, so those behavioural changes that owners, we can teach owners to associate with pain. So things that behaviours that the pet starts doing related to pain, and when we get that treatment right, how do those behaviours resolve?
What are those indicators that that pet's comfort levels are markedly increased? We mention adjunct analgesics, we need to work out when to add other drugs in. And of course, the importance of physical rehabilitation.
So a lot of this involves decision making and we're making decisions on a day to day basis. So how can we give ourselves a structure to make those decisions a little bit easier to make? What are we doing every time we're weighing the evidence.
There are 7 steps here, but I think step 4 is a really big one. Right now on the market, if we said, OK, management of osteoarthritis, particularly non-steroidals, there are 7 different non-steroidals on the market, so we have a lot of alternatives. Can we weigh the evidence and decide which one we should be using, and how do we choose amongst those alternatives?
We've seen in the past couple of years, we've got Galipran Grapirant on the market, so how do we decide whether to start our patient with Grapirant or a conventional non-steroidal? We're also going to be seeing a new analgesic coming from Zoit at some point. You may have heard rumours of this monoclonal antibody against nerve growth factor.
So this is something that's in the pipeline. I'm sure we're going to see it in the states before we see it in the UK, but if you have a search on that, you'll find some papers related to monoclonal antibodies. I'm gonna talk to you about some tools here about how you weigh the evidence and how you make that decision when to move away from what you've been doing, for the past however many years.
Do we move away from non-steroidals? Are non-steroidals still our first line? How do we decide when to use those alternative agents?
Can we appraise the evidence and decide that those are significantly better than what we're doing right now? We'll look at some things that I think are really important to help you out with that process. Really good in the UK particularly at practising evidence-based medicine, and I think to call it a buzzword, I think evidence-based medicine has gone from being a buzzword, it was probably a buzzword five years ago, to becoming accepted practise.
So ideally we're going to evaluate our use of a new drug based on randomised controlled trials, so the higher level of evidence. We are less keen on the evidence associated with things like case series or case reports, although we've got to accept we have to start somewhere. And actually, if I try a new drug, then I'd quite like to let everybody know about my experiences of it, but I'm always gonna say, well, actually this is going to inform the design and the structure of future studies to evaluate this analgesic, hopefully, as a randomised controlled trial.
So we need to take a bit of a critical eye when we look at some of these things. So we always say in anaesthesia and pain management familiarity is best. So what I'm going to encourage you to do is stick with your, what we're familiar with from an a multimodal management of osteoarthritis.
In this diagram you'll have seen similar types of diagrams associated with management of osteoarthritis. You've got to do all of these things, so it's not a case of picking one and ignoring a couple of the others. We have to do every single one of these.
When we know it works for arthritis and we know that we have that management structure, we're just gonna translate that direction and say actually which bits of this are relevant for neuropathic pain. You may be recognising that patient has neuropathic pain because they haven't responded so well to a non-steroidal. And so how do we manage that?
If we're talking about managing neuropathic pain and setting standards in how we do that, we're going to try one non-steroidal first. If that patient doesn't respond to that non-steroidal, we're going to try another non-steroidal. That's my standard approach for arthritis.
If we think about the etiologies of some of these neuropathic pain, if we've got disc disease in particular, there could also be an underlying osteoarthritis there. So it does make sense to try non-steroidals first, rather than jumping to the gabapentinoids, pregabalin gabapentin. But we have to know when to move on to that drug, and we need tools to work out when those non-steroidals aren't working.
And then if we try gabapentin or pregabalin or amantazine or memantine, how do we judge the efficacy of that analgesic? I touched on non-steroidal versus newer options. I think by the end of this you will have some understanding of evaluating the efficacy of those newer options.
I spend a lot of time talking to people about Grapirant, Galaprat at the moment, and I think what's not quite clear is when should we start a patient with grapirant? Should we use that on our freshly diagnosed cases of arthritis? Is it suitable for mild, moderate, or severe arthritis?
I think what we really need is to incorporate pain scoring every single time we're making that decision to prescribe either a non-steroidal or a pit rant, such as grapirant so we can have an objective as possible. So pain scoring is still a subjective method, but it's far more objective than, oh, the dog is a little bit better. So let's make pain scoring has to become a standard with management of any type of chronic pain.
We've got to know what we're treating. We've got a lot to think about in making these decisions. And Some of the pain scores that were used in evaluated graphics, so the canine brief pain inventory, this is the main pain score that I'm gonna talk to you about today, because it's very simple and easy to use and it's being used currently in a lot of the trials for new analgesics.
So pain's going is key. I'm sure you are familiar with your options. So Liverpool osteoarthritis in dogs, this is specifically for dogs with osteoarthritis.
I really like load, it's really useful for teasing out some of the information you want from owners with relation with regards to the dog's exercise. And so it stimulates that discussion. And what the dog should be doing exercise wise.
So I would say if you're trying to get a real handle on management of that case from an exercise point of view, load is really useful for you. At the end of the load score, it scores the arthritis as mild, moderate, or severe, very valuable in speaking to owners and saying this is where your pet is right now. Osteoarthritis is a progressive disease.
We need to monitor them to work out when they're moving up that scale, into that category, so we can work out when to provide further analgesia. I know a lot of you really like the Helsinki Chronic pain index. I do like the Helsinki Chronic Pain Index.
Personally, I've just spent more time using the Kine brief pain inventory. I find it's quick and easy to use, and I, I have a, a better experience with that personally. One of the pain scores I am gonna touch upon is the vet metric health related quality of life.
So so far we've got load which is for dogs with osteoarthritis. The can Ery pain inventory is validated for dogs with osteoarthritis and for dogs with cancer, certain types of cancer pain. I've written a case report where we use that for evaluation of dog with neuropathic pain.
Helsinki chronic pain index is fairly good across all types of pain, and that Metrica is scoring health-related quality of life. So it's really looking at how the pain affects the patient. And what we're trying to pull out with that and all of our pain scores is not how painful the pet is, we want to know how painful they are, but we want to understand how the pain is making the pet feel.
And that's what's referred to as the motivational effective component. So identifying those pain behaviours. Now something like the Ko Reef pain inventory doesn't specifically ask for pain behaviours, but as I'm going through that pain score, I'm talking to the owners and listening to what they're saying, so use it as part of your history taking, because during that process, they will verbalise things that you think actually that's a pain behaviour.
I'm gonna try and identify three pain behaviours associated with this patient that we can then use as outcome measures. As to the success or failure of our treatment. So those are two things that I think should become standard, so using pain scoring, but also identifying pain behaviours.
And I say that to clients, they sometimes don't really understand. The Severity of pain, I think we all get that, don't we? And I think something to explain to the client is, OK, how painful your pet is is one thing, but how does the pain make them feel?
And I often have clients say, well, I don't think he is painful. And I look at the dog and its elbows aren't moving anymore because there's no range of motion, and they're walking like a Queen Anne chair and I'm thinking, well, hang on, your dog is definitely painful. Then on further questioning, we can clearly identify pain behaviours.
Well, he doesn't want to go for a walk, he'll stop halfway down the front path. That is a pain behaviour. Your dog does not want to go for a walk because he's painful.
So there are these, I think we need to move on with how we talk to owners and make assessing pain behaviours one of our standards of not only osteoarthritis management but right across the board, all of those, those types of chronic pain. So we've got two things there already, pain scoring, pain behaviours. And in the process of doing that, it is really important to stage the disease.
And we have a tool for doing this with osteoarthritis. I don't think we, we're that yet, we are yet there with certain other diseases such as chronic disc disease. A lot more work on syringomyelia and severity of, how, how severe those dogs are affected with syringomyelia.
Maybe not as far as a staging tool, but let's use arthritis as an example here. So you can find the link to coast, so the canine osteoarthritis staging tool. There's this paper that is looking at the validity of the paper.
If you look on the American website, the Alanco website that they have for Gallopran in the States, you'll find a link to the interactive PDF. I don't know why it's not on the UK site. Maybe it is now and I've missed it, but the link I found it to that interactive PDF is the American Gallopran site.
And what we're trying to do is stage that disease. The team that developed this recognised that we need to get in there a lot sooner with managing arthritis. 50% are diagnosed too late.
I bet you if you were to use COA and stage most of your arthritis patients, or maybe you're already picking it up through load, you will recognise that most of your patients are in the moderate or severe categories. We aren't recognising those mild arthritis cases. And actually what I really like is an owner that presents their dog really early, and we recognise a mild osteoarthritis case because we are in the very best position to treat those patients.
Again, if staging disease becomes part of your standard approach to this, we're going to pick up these cases earlier. And this probably isn't within the context of an arthritis consultation, this is probably within the context of a routine health check. So on an annual or a six monthly basis, those breeds that are predisposed, your Labradors, your larger breed dogs, you should be going through some type of pain score to track those patients.
And that's given those owners a lot of time to understand the disease. They're not suddenly smacked in the face when the dog's 8 years old and, has moderate or severe arthritis. Your dog has arthritis.
They've had time to think about it, time to modify the exercise, time to do all of the other things that we hope are going to slow down the progression of that disease. So again, let's make staging diseases a standard for managing our chronic pain. How do we do this?
CMI on the left of this chart is clinical metrology instruments. That's a pain score. So it can be load, it can be the KM pain inventory.
We need to be using a pain score, so we grade the dog, we grade the joint, and then we assign a severity. So we're looking at discomfort associated with that. That's pain.
We're looking at posture, we're looking at how the dog moves. Then we examine the dog. Again, standard, a very visible physical examination is important for.
Ensuring clients understand the value associated with what we do, and they see the reason for bringing the dog back. Very difficult for us to do at the moment, but right now, what we can do is we can relay exactly what we've done examination wise to the owner and say, yes, well, I've examined both elbows, both stifles, both hocks. We see a limited range of motion in XYZ joint.
Pain or manipulation of the joint, physical examination, radiographs. We're scoring this from less severe down to most severe. Let me just pick that point laser pointer up, so on the right hand side here, so less severe, down to most severe.
You put a tick. In the box, and the further down the tick is in the box, relates to the greater severity, with then moving down here to assign mild, moderate or severe to the osteoarthritis there. It's much easier when you go through the interactive PDF, it explains it very easily to you.
You pick the index joint, so the worst joint affected, and just work your way through that. It's actually really quick, it's not prohibitive thing to do within the consultation, very quick and easy to do. And then we know exactly where the patient is and we can talk to the owner about appropriate management for that stage of osteoarthritis.
So staging helps, pain scoring really helps. OK, it's fine when everything's going right, but how do we approach the drug that's not working? And actually pain scoring is really important for picking up when the drug isn't working.
We know that we see a placebo effect in 30% of cases, which is pretty dangerous for us, isn't it, with arthritis, we want to provide a treatment that is going to be effective because this is a long term disease that's going to get worse. What's the worst thing, we put a dog on a treatment and it's not actually doing anything. So pain scoring can actually help us pull out when the drug isn't really working either.
And adding in pain behaviours again can be really useful. It's gonna help us to understand when we need that second analgesic. Another thing that's really important, once we get beyond non-steroidals and grappy brands, we're talking about entirely off licence options.
So it is really important that we can evaluate those off-license options. Just as an example, this is a dog that I've seen within the last 6 months. So isn't an 8 year old Jack Russell with spinal pain.
No neuro exam a year ago. At that stage there were no MRI changes. The owner reported the dog to be in pain, saying that the dog sits with its left pelvic limb, abducted.
Ortho orthopaedic exam at that stage was normal. Treatment a year ago was initiated with Carrofen, they only came to see me because they feel like the dog's pain is progressing. I use the Kine brief pain inventory with this case, and that scores, the, the first section, so the pain assessment section gives you a score out of 40, which if you divide that by 4, it gives you a score out of 10.
2nd section 6 question. So that's out of 60. Again, divide the overall score by 6, and you get a Out of 10, because we all understand the number out of 10, it's very easy to say to owners.
So this dog was scoring for the pain score. So how painful the owner perceived the dog to be was 5.7 out of 10.
And the interference, so how the pain interferes on a day to day basis was 5.1 out of 10. So we've got a baseline.
Do I use these scores to decide how severely affected a patient is? I don't really, I tend to use these as baseline and just take the, the absolute number and then use a comparison. I don't, there aren't really categories of saying this is mild, moderate, or severe.
If I want to do that, then I'm gonna add in my co score at that stage. What treatment did I do? I thought, well, OK, spinal pain, the dog is already been treated with a non-steroidal.
OK, yes, an option here would be to change the non-steroidal and see if we've got a better effect from another non-steroidal, so that is, that would be a completely valid option here. In this case, we had the gabapentin 5 megs per TID and I saw the dog back. What do the owners say?
He's a bit better, yeah. That is not helpful at all to me. So my first impression is, oh no, what am I gonna do now?
We've all felt that kind of heart sinking moment thinking, oh, I thought I'd made quite a good treatment choice here, but the owner thinks he's just a bit better. But when we pull this out in the pain scores, this is 28 days later, you can see that actually the pain scores dropped quite markedly, and the interference scores have dropped quite markedly as well. So that's how is your dog doing, and I do tend to try and not ask that question to owners, but how is your dog doing?
It depends entirely on the owner's outlook on life, on what scores they give you. So again, you can see the importance of actually putting some numbers to this and talking about those pain behaviours. So in that situation, the pain score did really help me.
So and then I can say to the owners, look, things have improved markedly. We know with chronic pain management, certainly for adding a drug like gabapentin for spinal pain, the evidence is fairly limited. It is based on anecdote.
It's right down at the bottom of that evidence-based pyramid. I can't pull tonnes of papers and say to you, you must absolutely do this as your second line. Where we're using trial and error, we need a little bit of help, as well as what the owners are telling us in order to work out whether our intervention is effective.
And this is a really clear demonstration of why I like using paint scores. We always ask ourselves what is significant. If we're talking about a visual analogue scale, so a scale of 0 to 10, then a significant reduction is 2 units.
That's accepted across a range of human pain studies. There are, I think if you look at some of the grappy prank work, they use the KM brief pay inventory. Obviously a significant reduction is totally dependent on the actual population studied.
So can I hand on heart say you should be expecting this reduction with successful treatment? I can't hand on heart say, because that is dependent on the population and the number of cases that we've used that pain scoring. But suffice to say we should be seeing a reduction in pain scores as our patients improve.
This is my osteoarthritis pain ladder. And again, when we're talking about introducing standards in pain management, we need a fairly standardised approach. We need to start with a non-steroidal.
And I, I am still of the opinion, and again, right down at the bottom of that evidence cascade. I'm looking for more evidence on this. I still think we should start with a non-steroidal versus grapiras.
I personally still think, and that is based to some degree on the literature available, I personally think that a non-steroidal is where we should start first line. So we're gonna start with a non-steril that suits the patient. We then need to work out when to progress to the next rung of that pain ladder.
And those drugs for me would be amantadine or paracetamol, and I'm gonna talk to you about why amantadine is my second line, and some of you will have heard me talk about this before. If the pain is persisting or increasing, we will work this out from our pain scores and our pain behaviours and talking to the owners, and then we talk about adding a third drug to that ladder. You can see there's sometimes some reluctance from owners and vets from adding in additional analgesics.
So having a standard approach in your practise that we think is as evidence based as possible. And we only move up those rungs when we have a clear indication that we need to. I think this is the best way to approach that sometimes undetermined field of pain management in arthritis and in neuropathic pain as well.
We've got to have something to base our decisions on. Nice example here. Seven year old Jack Russell with shoulder dysplasia, so this little dog had awful shoulders.
I'm sorry that's not a very good radiograph there, but her shoulders were completely dysplastic and she had secondary arthritis due to those altered joint mechanics. Probably a year previous to seeing me, prior to seeing me, she had been treated with meloxicam, and she did respond well. At one stage, she had an adverse event with the meloxicam, and so the meloxicam stopped.
And then the referring vet tried tramadol on Parddale as a combination which the dog did have some response to, but the low level of response was what triggered the referral to the pain clinic. So when I saw her, we did a baseline can and pain inventory, the pain was scoring 6.5, the interference factor was 6 on day 0.
Thinking rationally about this, I thought, well, actually, I know that non-steroidals are going to give the greatest benefits to this patient. I think of all of the drugs that we have in our armoury for managing chronic pain, the non-steroidals are safe and they are efficacious. We have the biggest body of evidence for using non-steroidals in pain management.
So we switched non-steroids, so we use rabenacoccib in this dog. Is there any evidence that one drug is more safer or more efficacious that isn't currently, so, pick your second non-steroid according to your experience in that regard is what I would say. Again, the most important thing is that the pet owner can get the drug into the pet.
We did that for 28 days and monitoring very closely for adverse events based on the previous adverse events that the dog experienced. 28 days later, you can see that the pain scores have both dropped by approximately 50%. So I would say that is definitely a positive response.
The owner was very happy with progress. So what do we do at this stage? We have a dog that is improved from the pain score point of view, the owner is reporting an improvement in those pain behaviours.
She's much happier interacting with the other dog. She wants to go for a walk, she doesn't stop halfway through the walk to be picked up and carried. We carry on monitoring that really closely.
We're going to, we've got the owner on board. We're going to stay in touch with the owner on a regular basis and as soon as anything changes, then the owner's gonna come back and see us and we're going to take that next step. So what is that next step?
In this dog, that pain did progress over time. We explained arthritis, progressive disease, things change over time. What our aim is to keep your dog as comfortable for as long as possible, and then we need to have a, a second level plan when the pain progresses.
And you can see from the Kine brief pain inventory here, that pain did change, going back to higher than it was previously. Now, in this case, Based on the literature, I'm gonna talk you through an NMDA antagonist is my second line, so Amantidine or memantine. Why do we use this?
What's the evidence formantadine? This is based on the Lasalle study from 2008 where they took 31 dogs with osteoarthritis refractory to non-steroidal treatment, and they were treated either with meloxicam or meloxicam plus amantadine. So all dogs had received meloxicam for a week and then a week later, Amantadine was added to half of that population.
And what they were able to show is the client specific outcome measure for activity, and they had a client specific outcome measure for behaviour. With regards to activity, there was a significant improvement in the Amantadine group from day 21 to day 42, and day 42 was when the study ended. Behaviour wise, there was no significant difference between groups.
But when the lameness was assessed by a specialist surgeon, the emanci group were less lame by day 42. One of the comments from this study was that the ability to perform everyday activities in subjects with limited mobility was improved by the addition of amantadine to the non-steroidal therapy. Now, this paper has informed my rationale for using NMDA antagonists as a second line.
I know we then throw in there amantadine or memantine. The only evidence we have is with Amantadine and this is this paper that I've just shown you. There is no published evidence looking at memantine, but it is something that we use as an option where either Amantadine is not available because it goes on and off the market, or the cost of Amantadine is prohibitive for the clients.
If you look on zero pain philosophy, there's some more explanation. It delves a little bit deeper into Amantadine or memantine to give you an understanding of why we may choose one versus the other. But that's my second line for arthritis management.
OK, I've got paracetamol on there. Do I honestly, can I honestly provide you with firm evidence about the, the use of paracetamol in osteoarthritis? Again, it's something that evidence is building on.
So for me, that's still a watch this space. Anecdotally, paracetamol is effective in certain cases. So together what I would encourage you to do is start with that as a baseline and take that as your standard approach within the practise.
So we're talking to everyone in the practise, this is a real team approach to say this is what we're going to do, we're gonna start all of those cases on monster rules for 28 days. There is evidence in people, and there is evidence in dogs. When you look at some of the non-steroidal licencing studies, when they use non-steroids for 6 to 8 weeks, over that period of time, pain scores improve for the full duration of that time period.
So we need to use the correct monthster order for at least 1 month, and we need to say to owners that you will see an improvement, and I think we know owners see an improvement within a week, but you will, we expect you to see an improvement for up to 6 to 8 weeks. That's what the literature tells us. It could be longer, but we don't know.
So we need to give the drugs a chance before we suddenly say well actually I'm gonna throw something else in right now. Now clearly, if a dog presents as a severe case of arthritis being diagnosed fairly late, we could very well start with a multimodal approach. Or you could start with a non-steroidal, see the client back in a week's time, see what level of improve improvement they've documented, and then start a second line drug such as Amantazine or Memanti.
You can see the importance here of staging that disease. So 11 Labrador presented for arthritis is not the same as the next Labrador presented for arthritis. And staging does allow us to take an individualised approach within a structured system.
OK? So this isn't the same treatment for every dog, it's an individualised approach within a common structure. If you've heard me talk anywhere else before, you'll say, you'll hear me say all osteoarthritis cases need a non-steroidal.
We know that vets certainly in the UK agree with daily non-steroidal dosing. We want efficacious drugs. We know safety is important.
We know that owners and owners under Medicaid, and actually we're not encouraging that. There are, if you look at surveys of different practises across the world, there are other countries where they will routinely encourage owners to undermedicate their dogs, whereas in the UK we agree that we should be dosing those non-steroidals daily to body weight. And we know that there are studies that show, particularly for meloxicam, there's a really nice study by Wernermeau shows if we drop below 60% of our recommended dose, we lose analgesic capture in the majority of those patients.
We know that owners forget what we say, but they do look online as well, so we need to be providing our owners with resources and information to back up our decision making, to prove to them in a way that this is why we're making the, the decisions for their pet and get those owners on board in that management. Little aside, something that's gonna help you, on the zero pain website under the pain updates, you'll find our 9 tips for non-steroidal use in chronic pain. So again, when you're talking about all of these things within a practise about creating a structure for how we manage the use of non-steroidals, these 9 tips will help everyone in the practise.
That's an infographics, so you can display it digitally or you can print it. So what does optimal osteoarthritis management look like in practise? We've got our diagram for the multimodal management of pain to follow, and we're going to assess all of those treatment options.
We're gonna train the vet team, we're gonna measure the pain, and we're gonna manage the clients. So if that gives you a broad structure. OK, then delving into assessing treatment options is something fairly advanced and there is, like I said, there's a fair amount of work to do there.
So that would be my standard approach. You have to do all of those things in order to see the optimal management of arthritis. And let's not think about other things until we've addressed all of these, and that is really important.
That creates owner buy-in. If you say to them, well, we have to do all of these things, and they're totally ignoring one element, and then they come back and they say to you, well, this isn't working, then you have a basis for further discussion will say this is what we need to be doing. So how do we then go further and assess other things that might be out there?
In the vet press saying well we should all be using this. One of my examples on this is laser. It's a question I get all the time.
Whenever I do a Q&A on arthritis management, people ask me about laser. So, how do we appraise the evidence and decide when we're doing all of those correct things for arthritis, should we then be investing in laser therapy for our patients? And there are now a couple of publications, so when I reviewed this back in 2017, there was only one publication looking at laser for treating dogs after hemi laminectomy surgery, which did report a positive response.
That was low level laser, you'll find that study in the Journal of Small Animal practise. So this study from the Open Veterinary Journal, I'm just gonna chuck in a few words of caution here when we are assessing evidence. The Open veterinary Journal.
This is probably a journal where it's easier to get your paper accepted, so I'm already a bit sceptical when I see the title of the journal. Preliminary, it means smaller numbers, not definitive. A short communication is not a full paper, it's not the, the information contained in this report is not worthy of a full paper.
OK, University of London, we think, OK, that's a fairly good institution, we're probably going to have some trust in what they say. Retrospective, retrospective studies fall further down the level of evidence. So it's not a prospective study.
We therefore question things like was there any randomization and it brings in all sorts of biases. 17 dogs, a really small number of dogs. Do we have a sample size calculation?
Do we know the power of this study? OK, they may produce some results and say there were differences, but do they actually have a big enough population to genuinely statistically prove those differences were valid? So already, even reading the title, it's the first bit of the paper, I have some reservations.
These are the outcomes that I drew from just reading the abstract of the paper. So be careful about just reading the abstract. So 170 dogs with radiographic and clinical diagnosis of osteoarthritis underwent low-level laser therapy weekly for 6 weeks.
The outcome measures used for pain scores used in the KNO brief pain inventory, I thinking, OK, great, that's a validated score for dogs with osteoarthritis. Pain scores with a Colorado state, chronic pain scale, and pain pain scores with a visual analogue scale. They showed with the CBPI that after these laser sessions, pain was reduced after the first session and decreased over time.
Pain scores with the VAS were reduced after the first session and decreased over time, so we're thinking, oh look, actually this is good, we should be using laser. They then say in the abstract was based on these results, analgesic therapy was reduced by the clinician at week 2 in 13 out of 17 dogs. These do state quite rightly, that this is a basis for future investigations.
And this work may help to reduce analgesic administration and improve client satisfaction. So I already have some issues with this here. Does the literature support the reduction of analgesics as an osteoarthritis management strategy?
I firmly believe that it does not. Why are we trying to reduce our analgesic use? There's no evidence that by reducing the dose of non-steroidal we reduce the adverse effects profile.
And we have a huge body of literature documenting the benefits of non-steroidals in the management of osteoarthritis. And I certainly would not be trying to reduce any analgesics two weeks after starting another intervention. I think we need to understand some of the intricacies and how we should be using the canine brief paint inventory.
So actually from a study point of view. What we should really do is score the pain at day 0, then score the pain at day 7 and take the day 7 value as our baseline, and then we should start our study and make our intervention. And that's documented by Dorothy Brown, who, invented the canine reef pain inventory.
So actually, if I was redesigning this study, I would recruit those owners at day 0. I'd examine the dog, I'd score the dog. I'd then see them back 7 days later to repeat that pain score, to give it the, the true baseline to avoid, regression to the mean.
I try not to alter two things at once, and I don't think you can evaluate the effect of laser over a period of 6 weeks when you're adjusting the analgesics at the same time. And ideally, these dogs would be on a standard analgesic management. So we would be staging those dogs on recruitment, recruiting dogs with moderate osteoarthritis, treating them with a non-steroidal and laser and leaving it at that as simple as possible.
One thing I would say is that the visual analogue scale is not a validated outcome either. And I know they made reference to the Colorado State Chronic pain scale, but that was only in the abstract, and there was no mention of that in the rest of the paper. So, perhaps those results were not significant, and we should always, even if we have results that aren't significant, we should all, we should report all of our results.
We shouldn't hide results that, maybe don't conform to what we want. The conclusion here was laser therapy in dogs should still be regarded as a mostly unexplored field, and more prospective clinical trials are needed. So I think that is your take home right now.
Can I honestly convince you to go out and spend X amount of money on a laser because it's gonna make a massive difference? One owner saying that it made a difference in my dog is not enough evidence for us to be able to say that. This was a retrospective study, so all those owners knew that their dogs were receiving laser treatment.
So again, that's a massive . That's a huge bias that I think totally influences this paper. But on the slightly more positive note.
This is a study from Canada looking at using laser in dogs with elbow osteoarthritis that did report a positive benefit. This was a blinded placebo controlled study, so it's doing all of the things that the previous study didn't. But a small number of dogs, so only 20 dogs there, 10 in the laser group and there are actually, sorry, 11 in the laser group and 99 in the, the sham, laser group.
They received laser to the elbows for 6 weeks. So I think yes, this study does give us an insight that there may be an advantage here in using laser, but we want to see bigger studies. I think we really need to see bigger studies before we say to owners, yes, this is gonna make a massive difference to your pet.
I think there are far too many biases involved in owners and the use of laser right now to reliably say that this is definitely making a difference. And I'm still not entirely on board with the concept of trying to reduce our analgesic medication for these patients. Again, like I say, no evidence dose reduction reduces NSAID adverse effects, and there's a small sample size there.
So I hope that gives you some idea of how we should be critically appraising the evidence. And we should be using that to put a business case together to say yes, we should be spending 10,000s of pounds on laser. We are comfortable in charging owners X amount every time we see them.
This is our protocol we're going to use. We, we are fairly sure, based on the literature that this is a sensible intervention. If you want to delve a little more into this, this is one of the RVC podcasts which I absolutely love.
Dominic Barfield does a fantastic job of chairing these podcasts, and this is one by Adrian Boswood on how to read a paper. And I really like, his approach to reading the paper, so you should read the title, have a very good think about the title, whizz down to the results and make your own assessment of the results before reading the discussion. So have a listen to that, it's, I think that's one of the best podcasts that I've listened to in the past year.
Right, so that's an idea of pain scoring, pain behaviours, and assessing the literature as part of adding things into more than our standard plan. And we touched on the owner several times, haven't we? So.
I think this is a disaster for every vet practise. The vet said he has a bit of arthritis and charged 90 quid for some Mescal. What a rip off.
I think we've all heard clients unfortunately, when we hang out on Facebook, we see these things on Facebook all the time. What went wrong here? Are we doing this?
How can we do this better? I hope If we look at that standard approach to managing pain and everything I've talked about so far, we're never gonna find ourselves in this situation. So what would you change about what happened in that circumstance?
Can we realistically do an OA consult in 10 minutes? We certainly can't, and I think there's a huge role here for osteoarthritis clinics, and they need to be. The vet team.
This needs to be vets working with nurses, working out who, who is needed, who is the most appropriate person to do each stage of these consults. So again, when you're working out your standard approach to pain management, we need to take a step back and actually appraise the situation in the practise, and it is that actually what we want to be offering and what we should be offering. What resources do you provide?
We already said that owners disappear when they read stuff on the internet because they probably only remember 30% of what we told them. I love canine arthritis management as a resource, and I always say to owners, if you're online, if you're looking for information, that is the only place that I want you to look. If you have any questions with it, come back and talk to me about it.
I don't want them talking to Brenda on Facebook, and I don't really want them looking anywhere else at Metam killing dogs and cats. Do you involve the vet team? I just mentioned that we, this is a a a whole team approach, even down to the receptionists.
So do the receptionists understand what we're trying to achieve with our arthritis patients? Owners sit there waiting for their appointment and they have a chat to the receptionist, and they tell receptionists things that they don't tell the vets. So again, if that owner says, oh yeah, the dog always stiffening up a bit when he's coming in for his routine vaccination, the receptionist just pops her head in and says, Oh yeah, the clients said he's stiffening up a bit, you might want to pick up on that.
That's hugely useful. That's gonna benefit the pet because we've involved the whole vet team. So I'm really passionate about getting everybody involved in the pain management process.
Another way I think is really useful for engaging owners and onboarding them with management of their pay is that metrica. And this is the health related quality of life measure created by the team at Glasgow that created the acute pain scales for dogs and cats. And you can use that metrica for dogs and cats as well.
It asks questions across what they refer to as 4 domains, so they are energetic and enthusiastic, happy and content, active and comfortable and calm and relaxed. And the way the questions are answered, I think, it's very cleverly designed from a psychometric point of view in order to perfectly gauge how the pain is impacting on that patient's quality of life. This is the output that I see, it has an owner section on the website and it has a vet section.
This is a subscription service so your practise will pay an annual fee for this. It's not terribly expensive, it's about 300 pounds a year, so it's not hideously expensive, if you're gonna use it. And you can clearly see here, this assessment started on the 21st of April, and we can see over time that that patient has deteriorated over time.
We get a flag, we can talk to the owner about it and say, we can see things have changed and we need to make an intervention here. This is the output that the owners get and it clearly says 70% of pets will score above this line, and you can see for this dog here in particular, he's scoring below all of those. This was a little whippet that I was managing.
The owners were really, keen to avoid surgery in him. He had a foraminal stenosis, in his lumbar sacral spine, and he needed surgery to release, the nerve, the nerve impingements, running through that, that foramina. The owners were really, really keen to optimise pain management and hopefully avoid surgery.
And we could, you could clearly see from the assessment here that whatever we were doing was not working. And this actually really helped both myself, the owner, and the neurosurgeon to understand that yes, we have tried as hard as we possibly can, but we cannot get your pet's pain under control enough and we are now resolute that surgery is the only option. So pain scoring and quality life assessment can help us with some of those really difficult decisions.
So do you feel equipped to get those plans in place to optimise your management of your pain cases? I hope you can see that a a vet team approach is required and. I hope you now have an idea of the tasks required of the whole team and things we need to think about to create that structured standardised approach to our pain cases.
I would use osteoarthritis as your baseline plan because 80% of our chronic pain cases are osteoarthritis in dogs and cats. And then if we're very familiar with how we manage those, it becomes easier to manage those neuropathic pain cases, so those, those chronic spinal pains, for example. We should really be working to evidence-based threatening management standards, and we talked through that with our assessment of low-level laser therapy and whether we should incorporate that.
And you can now do that for any new treatment that comes along. So make your own assessment when the, the monoclonal antibodies to nerve growth factor comes along. Score the pain, I think I've reiterated that enough that it is so important that we score the pain.
Everyone's familiar with the scores that we're getting and how we do that. And clearly we all recognise the importance of involving the clients in that management process. So I hope that gives you some structure.
I think like I say, everyone will gain more job satisfaction, your client outcomes will be better and you will be able to generate a little bit more revenue from your pain management clinics in that regard. So thank you ever so much for listening. If you have any questions then I'm happy for you to contact me.
You can do that through the Zero Pain Philosophy website and I'm really happy to help you anytime.