Hello, welcome to another one of the webinarett's webinars. Today we're very fortunate to have John Wahouse speaking about surgical and non-surgical options for osteoarthritis treatment. John is a veterinary surgeon who graduated from the University of Sydney and then went into general practise.

He now lives in America, where he studied and undertook a fellowship in pain management. And rehabilitative medicine under the direction of Doctor James Gaynor at the Peak Performance Veterinary Group in Colorado Springs. John is very interested in veterinary orthopaedics and sports medicine and is a certified canine rehabilitation practitioner.

John, it's over to you. Hello everybody, and thank you for that introduction. It's always a pleasure and really an honour to be able to present to the webinar vet audience.

Now today's webinar is on a huge topic, when they ask, can you talk about surgical and non-surgical options for osteoarthritis, I laughed and I said, you're only giving me an hour. But before we get in and talk about what we're gonna talk about this hour, I just want to step back and do a little, who am I, if you missed the introduction. So my name is Doctor John Waterhouse, I'm a licenced Australian veterinarian.

I came out to the United States back in 2010 to undertake a fellowship in pain management, sports medicine, regenerative medicine, ideally to take back to Australia, but we know things change and 11 years later I'm still here in the United States. I undertook my CCRP training at the University of Tennessee back in 2013 and 2015 was involved as a consul was involved in the construction of a 1500 square foot rehabilitation facility in Colorado Springs for six orthopaedic surgeons where I wrote the protocols and trained the staff and did a turnkey. Back in 2016, my wife, Doctor Celia Waterhouse and I started the Veterinary Teaching Academy.

To take all that information that we had learned over the last two decades and put it into educational programmes to help train you to be able to do a better job in the consultation room and with your clients at the end of the day, your patients are the ones that win. Now last year with COVID, we pivoted because a lot of our students or members of the canine rehab Teaching Academy were asking for programmes that they could do and give to their clients while they weren't able to see them, so we launched the canine rehab on Demand programme series. And that programme series at the moment we have the top 10 most common orthopaedic conditions, so here's an example of the elbow dysplasia programme where the your clients get access to the educational webinars that I've.

Trained veterinarians on for the last 6 years. We also have a 12 week home rehabilitation programme where they go through and every 2 weeks that unlocks the next 2 weeks, and I walk them through videos on how to work with their pets at home. We also give them a nutraceutical and pharmaceutical twelve-week guide designed specifically for that disease, and we'll talk more about that as we go through the slides.

They also get a modality checklist, which modalities are appropriate and not appropriate for those disease conditions, an equipment checklist and so much more. But this is just an example of one of the programmes that we have that you can give and, To your clients and actually get an affiliate fee back for referring those programmes, but we'll talk more as we go through this webinar. So what are we gonna be talking today?

Today we're gonna be talking at treatment options available for osteoarthritis, both surgical and non-surgical. Really we're gonna go quickly through the surgical options and then get more into the non-surgical options because this is where the meat and potatoes are. It.

It doesn't matter if they have surgery, they're still going to develop degenerative joint disease later on in their life. So we need to address for non-surgical and surgical patients, a degenerative joint disease medical management programme, and that's what we're gonna spend the majority of this webinar talking about. And in the non-surgical option, we're gonna look at a multimodal approach, we're gonna look at what supplements, what pharmaceuticals, what modalities work, and I'm gonna do the top 5 for each because we have not enough time to deal with the contents.

Each one of these areas could be its own hour, 2 hour webinar, and they are webinars in my programmes. I've been asked to condense it down into 1 hour, so I'm gonna give you my top 5 picks in each of these areas, and then we're gonna finish off with regenerative medicine. So, let's look at the surgical options first.

So when we think about surgical management, things we need to think about, ah, what is the degree of lameness, what range of motion do they have? What is the age of the patient? Are they a good surgical candidate or not?

Is it bilateral or unilateral, as in, are we bilateral elbows, bilateral hips, or one stifled joint? What is the degree of joint disease, and are they a good candidate for surgeries that I said before? Everything we're gonna do, we're gonna do with arthroscopic evaluation and arthroscopic surgery.

Really it's only cranial cruciate disease where we open the stifle joint. Now everything we're doing is really with arthroscopic surgery or evaluation. And arthroscopy is the gold standard, and we're able to look at all the structures and the inarticular structures and the soft tissue structures of the joint, mainly with the shoulder and the stifle joint, elbow joint and we're not, there's no soft tissue structures running through those joints.

It allows dynamic, Evaluation of that joint, and we can palpate the articular structures with probes and see if there's OCD lesions, FCPs, fractures in that structure, but also we can poke and prod and look at the soft tissue tendons and ligaments running through that joint, and it is minimally invasive. Here's an example of what it looks like in the shoulder joint. So if we have frayed tendons, we have lax laxity, disruption to the fibres, fraying of the fibres, that's what it looks like on the upper right-hand photo.

We then can evaluate the joint capsule. So down below we have here the probes going in, you can see fracture of that articular cartilage. So it is a great mechanism to evaluating the joints.

When we look at the shoulder and the elbow joint, we're looking for arthritis, so radiographs are also great. And so the arrows are pointing out where areas of lytic changes are, bone spurs and degenerative joint disease, classic ostolytic changes to the joint. And so when we're looking at surgery procedures, we're looking at reducing that joint, cleaning up that joint, helping slow down the progression of degenerative joint disease.

And so surgery is undertaken to remove, so with our elbow joints, we have UAP or ununited a canal processes, FCP's fragmented medial coronoid processes, or OCD lesions, and that's an osteochondroita dissiccant. And we go into great detail in the elbow dysplasia webinar series in this, but really, These are the pictures on the right-hand side show with the arrows you have then, OCD flap, or you have, and then once the lesion's removed, you can see where the grinding of that joint, we think of the pebble in the shoe, we need to relieve that joint mouse, that flap, it's like a rock that grinds and once it's relieved, we can then address that. And so other surgical alterations, we're looking at changing the angles of joints.

The elbow is the classic example. We cut the radius and ulnar bone as the images show here with plates and we can change the angles to that joint to hopefully slow down the development of degenerative joint disease. When typically we are doing surgery and we're doing it with immature dogs that are suffering, especially with elbow dysplasia, elbow injuries, FCPs, OCD lesions or UAPs, and usually they have one or they can have 2 or all 3, and we see the combination, we don't know which one starts first, so all three are starting at the same time.

Are concurrent with elbow dysplastic disease. Or we can do surgery with mature dogs that have mild to moderate osteoarthritic changes or degenerative joint disease associated with some form of joint instability. These are the good candidates, the young and the mature dogs for surgical options.

What do we do with surgery, as I said, we want to clean up the joint, remove any soft tissue structures, any hard tissue structures, joint mice, flaps. And so if we look on the right-hand side, these are diagram diagrams that I created, I hope you like my artwork, to explain what is done in the procedure. So the joint flap is removed.

Once it's removed, we go in and we do something called microfracturing, where we go and we henpeck along the cartilage to create blood supply trauma to that joint because we know cartilage is traditionally very poor in blood supply. And so if we can henpeck create bleeding, creates trauma, we grind down any rough area. This allows the body to create secondary scar cartilage.

It's not as good as the pre-injury cartilage that's the hyaline cartilage, that lovely smooth cartilage, but it is a secondary scar cartilage that has some viscosity to it, and it allows the joint not to be rowing bone on bone, but on some cartilage material. The hip joints, and these are really hard joint because it's encapsulated in bone. It's a moving pivoting point.

We can't get an arthroscope in there to clean up, so we're very limited with what we can do with the plastic hips. The two main procedures are femoral head osteotomy, that's where we remove part of the femoral head, the condyle, so the ball out of the socket, and now you have a free floating joint and over 3 to 6 months we get secondary scar tissue formation or a false joint forms in there to take the place of the ball and socket. And so this is really good for mature dogs, dogs that weigh less than 17 kg or 37 pounds.

Some cats or cats, this is fantastic for, and physically fit dogs that have well-developed muscles, we need that soft tissue structure to hold that ligament that now that false joint in place. Who's not a good candidate for this? So dogs younger than 7 months of age, because we need those growth plates to close, especially on small breed dogs.

Dogs weighing greater than 17 kg or 37. Pounds. Large breed dogs or dogs that are obese and overweight or unfit and have lacking or atrophy to that muscle structure because we need those muscles to hold that joint together while the fibrous joint forms over the 3 to 6 month period.

The FHO procedure, as I said before, it's removal of the femoral head from the neck, so we go in with a saw and we cut off that femoral head, and now we have the two bony prominences, the hip joint and the femur moving in space, but they're no longer touching and that is where the pain relief comes from. Other things that we can do is total hip replacements. We're actually replacing the femoral, the head of the joint in the femur with an artificial joint.

And so this is where the ball of the femur is removed, the cavity of the. Femur is drilled out, a shaft is put into the socket of the acetabular cup, and also a femoral head implant is put in and then the joint goes back into place. Who was a good candidate for this type of surgery?

Dogs that are older than 10 months of age, so as before with the other procedure we know need the growth plate, both the hip and the femur too have closed. Dogs weigh more than 18 kilogrammes or and 40 pounds, so if they weigh less, they're good candidates for the previous procedure, but heavier dogs are great candidates for. Total hip replacement.

They need to be overwhelmed good health, no other bone disease or no other skin or bladder infections. Who isn't a good candidate for this procedure? Dogs that are younger than 10 months of age.

As I said before, dogs that weigh less than 18 kilogrammes or 40 pounds. Small breeds, cats, but some cats are, so think of our Maine Coons, things like that, they could be greater than 18 kg or 40 pounds. Obese or unfit dogs and dogs with chronic skin or bladder infections because we don't want an infection into that implant and dogs that are uncontrollable will jump around, can't be kept quiet because we don't want them damaging that implant in the healing process.

So in that procedure, as I said before, we remove the femoral head off the neck and this eliminates the. Contact between the femur and the pelvis and we replace that with a ball and a plastic cup, and that becomes an artificial joint. Stifle joints.

Now the stifle joint is a lot like the shoulder joint because we have ligaments and soft tissue structures running through that joint. We have the cranial and caudal cruciate ligament. But in this radiograph you can see all the oscilllytic changes that are associated with degenerative joint disease and the the stifled joint.

So in the surgery, much like the shoulder surgery, we wanna look at the soft tissue structure and the hard tissue structures for laxy, disruption or fraying of the tendons. We wanna look at the architecture of the joint capsule and the archi and the architecture of the articular cartilage as well. Very much like the shoulder joint, we go in any hard tissue structure deformations, we remove the flaps, the joint mice, we grind down any wearing out of the cartilage to then and then go in and do the micro henpecking again to create trauma, to create blood supply and to stimulate the healing cascade or the inflammatory cascade to come in and start laying down scar tissue cartilage.

So let's look at the multimodal approach. I know I'm going fast because we have a lot to go through, but now this is where the really the exciting part of the presentation starts because really surgical procedures, it's all the same, it's cleaning up the joint, trying to create a scar tissue, cartilage formation and now dealing with the onset of degenerative joint disease. So.

The multimodal approach, we wanna look at, this is my multimodal approach wheel, and we wanna look at good pain control, weight control, and EPA rich diet, physical rehabilitation, daily exercise, and condu protectives all make up the wheel of a multi-modal approach. And the goals of treating osteoarthritis with a multi-modal approach is we want to reduce pain, we want to improve strength, Muscle mass, we wanna restore function to that limb or that joint, and we wanna reduce inflammation associated with the eugenic joint disease and that joint or joints. So with medical and surgical treatment options, we seek to alleviate pain.

Maintain strength and muscle mass, reduce the instance of degenerative joint disease or concurrent injury, reduce or regain or retain function and improve the patient's comfort and quality of life. So let's talk about pharmaceuticals in my top 5 pharmaceuticals. When it comes to treating osteoarthritis.

So the first one, and this is really, really exciting, and this is anti nerve growth factor, and in Europe and the UK you've had it about a year, the US, we're about to get it in the next couple of months, hopefully, or a year, but this is going to be a game changer in how we treat a degenerative joint disease patients. Galy Pratt is another fantastic new drunk that's been on the market probably 2 years now in the States, and there's been a game changer in how we treat pain. Aequine and cartrophin, depending where you are in the world, the US you have Aequine, you can't get your hands on cartrophin.

The rest of the world you can get your hands on cartrophin, but you can't get your hands on adequine and we'll look at both of those. And then we always have to talk about non-steroidal anti-inflammatories. So let's talk about this new exciting two new drugs that have come to market.

So anti nerve growth factor. And so Zoattis has brought out a canine and a feline version of an anti-nerve growth factor in the last year. So what is an anti nerve growth factor, and this is all about monoclonal antibodies, and these antibodies have a highly specific immune system proteins that target and neutralise molecules involved with osteoarthritis disease in the joints all that inflammatory cascade.

So anti NGF functions more like, A naturally occurring antibody, and this is really exciting what it's going to do for our osteoarthritic patients because we know osteoarthritis is an old disease, and we're maybe seeing in our geriatrics and they already have liver or kidney disease, especially for our feline patients. And so being an antibody or monoclonal antibody, it is processed as a normal protein, so it degenerates or degrades under natural pathways and very little liver or kidney metabolism is involved, where we know with non-steroidal anti-inflammatories, it's all in liver and kidney metabolism, how it's broken down. So these class of drugs can now be given to Geriatrics that have liver and kidney issues.

In the studies they gave it to class 1 and class 2 renal disease, they didn't give it to class 3 or class 4 end stage, because they didn't want that to muddle up their research, but because very little is, metabolised in the liver and kidney that I'm so excited about, that we now can probably give it to our chronic kidney and liver fail failure patients to give them pain relief, because it's all about quality of life, not extending life, it may shorten their life, but we're talking about quality of life here. So, with osteoarthritis, we know that the nerve growth factors bind to the receptors on the neurons and also the immune cells which results in pain. And the release of pro-inflammatory mediators, so in the more the nerve growth factors we have in the degenerative joint disease soup, the more pain, the more inflammation that we get.

So if we can have an anti nerve growth factor goes in and binds those nerve growth factors, we now get pain relief, we now get reduction in the inflammatory mediators in the joint, and we get a reduction in neuro neurogenic inflammation. And that's what it does. That's the real exciting part of this is we get to down regulate pain, down regulate inflammation and down regulate those neurogenic pathways, so we're getting pain relief.

And this is huge for our feline, especially because very limited things are out on the market for our feline patients but also for our canine patients as well. So The studies also showed that there's no known interaction with other medications in the clinical study. So this is really great because we can be prescribing this because it's a once monthly injection with other other vaccines, medications that they may need for other medical issues.

So as I said before, this is a one month vax or injection, and this is gonna revolutionise how we treat our or geriatric patients when it comes to degenerative joint disease. Another drug out there is Gallirant, and Gallirant is a newish drug when it comes to the non-steroidal anti-inflammatory category, and it's active ingredient is gayrant, and it's a non-COX inhibiting prostaglandin receptor antagonist. Woo!

Got that all out in one mouthful. And it's mechanism mechanism of action is that it blocks the EP4 receptor responsible for pain and inflammation associated with osteoarthritis, so it's just blocking that receptor site that experiences pain. Patients were given 15 times the label dose over 9 months period and it showed no liver, kidney increase in enzyme or increase in function.

And this is great because it also had no gastrointestinal tract issues as well. So the real powerful part of this that we saw was no side effects that we commonly associate with a non-sterileal antiinflammatory. So no kidney raising kidney enzymes, liver enzymes or gastrointestinal disturbances, vomiting, ulceration, other things like that.

So it's also safe to give the puppies after 9 months of age or dogs that weigh less than 8 pounds. So this is huge, so we now have something that we can give to younger dogs to help with the pain that we traditionally didn't have with non-steroidal anti-inflammatories. Adequine, one of my go to's with degenerative joint disease, and this is an injection and Aequuan belongs to its own unique class of drug, and it's a modifying osteoarthritis drug, and this is, as I said, an injectable and it's a polysulfited, Glycoaminnoglycan, woohoo, another big word that I got out correct or PSGAG is commonly referred to, and this is in the United States, the only drug in this class that's approved by the FDA.

So how it works, it helps, it works in three ways, it helps heal damaged cartilage early in the disease process, helps interfere with the catabolic enzymes associated with joint inflammation, and also helps slow down the progression of degenerative joint disease and it enhances certain anabolic enzymes in the joint. So Aequine has clinically been shown to help treat osteoarthritis disease in providing relief from pain, modifies the osteoarthritis disease cycle, or degenerative joint disease cycle, and has been shown in some cases to stimulate stimulate cartilage repair process that diminished joint damage. And reduces pain associated with osteoarthritis.

So now we're giving this early and earlier, so working dogs, dogs that we know that are going to be overloading their joints, we're now putting them on a programme of adequin to help prevent. Degenerative joint disease. Dogs that suffered joint injuries, hit by car traumatic events, I'm now putting on adequine to give the building box to slow the development of degenerative joint disease that we know will be coming down the track.

Cartrophin, so if you can't, if you're in the United States, you have adequine. If you're in the UK, Europe, Australia, you have cartrophin. Oh, with Adequine, if I go back a slide, we give it once, it's in the label, it's saying twice a week over 4 weeks.

Sometimes I find patients can suffer diarrhoea if it's given twice a week. So I like to give it once a week over 3 weeks and then once a month after that. If they're a large breed dog or a dog that has, Big underlying degenerative joint disease, I'll then give it Twice a week, but I'll stagger it, and I'll do that over 3 weeks, but I'll give it, instead of every 7 days, I'll give it every 5 days.

So they're now getting more doses over the 3 week period. We know you can give it twice a week, or try it. It has a great leniency, but I like to give it either 7 days or 5 days because especially in large breed dogs are getting a big dose.

It helps cut down any loose stools that may be associated with the body getting used to this supplement or this pharmaceutical. With cartrophin, this is a. Peno Pentosan polysipate, and this stimulates chondrocytes to synthesised cartilage matrix.

It improves the quality and quantity of synovial fluid, that nice stringy, viscous feeling fluid, and improves and increases blood supply to. The joint, and this increases nutrients to get there, helps wash away all that horrible negative, toxic environment in the joint and bring nutrients in there and helps prevent and support the subchondral bone. It's also been shown to have a strong anti-inflammatory properties.

It stimulates improved growth factors that promote cartilage growth, increased production of free radical scavenging enzymes, and stimulates important growth factors that promote cartilage growth. And so with Cartrophin, we want to give it, it says on label once a week for 4 weeks, and then we give it once a month after that. We always have to talk about non-steroidal anti-inflammatory because they're still the mainstay of degenerative joint disease treatment.

They're your breakthrough pain days, they're your back-up drugs, and so we need to always think of them, if done properly non. Steroidal anti-inflammatories are a fantastic drug, but we need to treat them with the care that they are. But I'm so excited that we now have new drugs coming down the pathway that give us pain relief without having to look at liver or kidney metabolism of drugs.

So here's an example of the Nutriceutical one week programme for our osteoarthritis programme. So you can see what we do with nutrices because there's a lot out there. And this is just a checklist that clients love because they can tick off when they're giving those nutraceuticals, and you can track when they're giving nutraceuticals, but also add pharmaceuticals to this list.

So here are my top 5 nutraceutical supplements, Daouin, Duolactin, Kiniva, Welactin and myos. So Daequin is a glucosamine chondroitin, and this is from Nutriax Labs and the real important part of this is it's a low molecular weight chondroitin, so it can be absorbed by the gastrointestinal tract. All other chondroitins on the mark are a high molecular weight and they can't be absorbed.

It always so uses manganese as the carrier transport to pull it through the mucosal membrane because also chondroitin is very poorly absorbed, so it needs transport carrier to get it across the gastrointestinal membranes. Also has so glucosamine chondroitin also has ASU avocado, soy bean, unsafonofiables, that is an anti-inflammatory in itself a natural anti-inflammatory. So this combination in Dain helps inhibit the expression and the production of inflammatory mediators in the joints, but also gives the building blocks to the joint to help protect and rebuild cartilage.

Dualactin is another one of my go to supplements, and duralactin is a microlactin, it comes from a milk-based protein. And it helps with anti-inflammatory and inhibits neutrophil migration through soft till, soft tissues to the site of injuries. I know I'm going fast in this, I'm just touching these slides because we have so much to go through in this hour, and all of this goes into great detail in my osteoarthritis webinar series.

But really we want to think of, this was a study where they were milking hyper immunised cattle, and the old farm dog was drinking the spilled milk out of the vat and 4 weeks later it was running around like a puppy and they're like, wow, what's going on here? And it's called microlactin. Microlactin inhibits the neutrophils from being activated to go to sites of inflammation associated with eugenitive joint disease.

So we can prevent the neutrophils going through soft tissue to the sites of the joint, we can remove the heat and the inflammation because when the neutrophils get there, they release their cocktail of enzymes, and they palm that joint, and that's that heat and redness that is associated with degenerative joint disease. So as I said before, neutrodolactin inhibits. And reverses neutrophil attachment to the blood vessel walls, and this prevents them moving through soft tissues of the sites of inflammation.

So here's some reference of some studies if you're interested. Also dolactin maintains joint. Tight joint junctions between the membranes of the cells, so it keeps the neutrophils in the bloodstream and preventing them to leaving the bloodstream so they migrate through those soft tissues to the sites of inflammation.

Canniva, this is a fantastic product out of Canada and it's ground up elk antler. And so Kniva also has glucosamine chondroitin. It's great anti-inflammatory, but really what I love about it is it's muscle building attributes.

So, it has a mild anti-inflammatory effect, but also it helps reduce or slow down disuse atrophy. Helps retain the tensile strength of existing muscles and helps helps build muscles, so I get all my post-surgical patients on this if you know it's a cran cruciate ligament. A hip dysplasia, elbow dysplasia, and they're going to go to surgery, I try and get them on this supplement at least 4 weeks before surgery because we're protecting that soft tissue structure to protect it from muscle disuse atrophy.

So another one of my top 5 supplements is omega 3 fatty acids. And these are really important and my number one goal is to get enough EPA and DHA into my patients. And the best way I do this is concentrated salmon or, or Weltin is a great product that I use because you just pour it on the food, there's no dosing and messy, messy breaking, Fatty acid capsules or fish oil capsules and it goes everywhere.

This is you just pour it out of the bottle onto the food. So we know there's EPA and DHA and arachnodonic acid, and this is all important in the, Arachnoic acid cascade. So we have omega 3 fatty acids and arachidonic acid then become and stimulate prostaglandins, and those prostaglandins stimulate pain, swelling, and neutrophil activation, and we just talked about that with dolactin and that all creates synovitis in the joint.

So if we can introduce omega 3 fatty acids, this goes in and blocks the arachnoidonic. Cascade, and if we do that, we then block all the prostaglandins, the pain, the swelling, and the synovitis in the joint, and this is what omega 3 fatty acids are so powerful in their anti-inflammatory effect in blocking the omega 3 fatty acid cascade or the arachnodonic cascade, as the digaman shows on the right-hand side. So MAS is another new formula, it's just come out on the market probably about a year ago in the United States, and this is another game changing formula.

So Mia is a bioactive compound that's derived from fertilised chicken egg, and it helps increase muscle mass, lean body mass and also muscle strength. And so how this does it is by down-regulating the inhibit pathway, and this also slows down muscle degradation. That's really great when it comes to disuse atrophy in our patients when they've got degenerative joint disease or undergoing some type of surgical or splinting procedure.

And this does this by upregulating the MTOR pathway to promote muscle synthesis. And it does this by lowering the myostatin in the blood to promote muscle growth because muscle growth is promoted by myostatin. The higher the myostatin level, the less we're likely to build muscle and the more likely to cannibalise the existing muscle.

So we know that we age. As we age, the myostatin levels, protein in our blood goes up, so we know we find it harder to put on muscle. Same with our patients, but also in disease states, myostatin levels rise.

So what my. Does myo does when the human version yoke does is it blocks the receptor site to trick the body into thinking that it has lower levels of myostatin than it than it does in the blood, so the body now produces muscle. So let's talk about joint injections.

And so joint injections, we're looking at the shoulder joint, the elbow joint and the carpus joint and the forelimbs, and we're looking at the hip joints, the stifle joint, and the hop joint in the hind limb. We can also do injections along the spine, but really they're the, the six main joints that we look at when we're thinking of degenerative joint disease and joint injections. So what are my top 5 intra-articular joint injection substances?

So regenerative medicine are up there on the list, but we're gonna talk about those later, but I wanted to put them on the top 5. Steroids, hydrouronic acid. Arthromidvet, spring, Sinnovitin are my top 5, but you see there's 6 because I slip regenerative medicine in there, so I thought I'd give you 5 other ones to to round it out.

So we'll talk about regenerative medicine later on and where stem cells and PRP and a combination come into their own. But let's talk about steroids, and steroids have their place. They go in and out of fashion, in and out of how you use them, how many doses you can give in the life of a patient to a joint, but steroids are very, very powerful and very, very great if they're used properly.

So I like to talk about dexamethasone is one of those steroids, there's a lot of other steroids that people use, but I'm just putting this slide here to tell you to always remember steroids because they can get on top of those inflamed joints really really easily and they have a place in degenerative joint disease into articular injections. Number 2 is hyaluronic acid for injections, is fantastic and can be used in combinations with regenerative medicine and other supplements, but hyaluronic acid is very powerful. But it, you must choose a bioidentical hyaluronic acid that has the same molecular weight as the species that you're putting in.

So we no no canines need a high molecular weight hyaluronic acid. And this helps preserve joint mobility, alleviate swelling and pain associated with eugenic joint disease because you're flushing. I like to use the analogy of putting new oil into an old engine.

And reduces those free radicals running around in that cocktail or that septic soup that I like to think of is a degenerative joint disease joint. Now we have 2 non-biological injections, or actually 3 non-biological injections that are now coming to market that really will revolutionise how we treat intra-articular joint injections. The first one is Arthromed vet, and I was involved with their initial studies with Doctor Jamie Gaynor.

Oh wow. About 6 or 7 years ago, we, we finished up our studies on the Arthromed vet. And what this is is a 2.5 cross-linked.

Polyacrylamide hydrogel, so it's a gel, and it forms a spacer between the joints, so you're no longer getting bone on bone grinding, you have the little rubber spacer in there. And it's a perohoogeneous, viscoelastic type properties injectable gel. And so it's a sterile neutral biocompatible with no biological or chemical action.

So it's an inert rubber, so I think we're just injecting rubber into the joint that now the bones glide against. It provides a viscosupplementation, so a lubricating cushioning. Similarly to hyaluronic acid, but with hyaluronic acid that joint can still be squashed.

This actually puts a space or a physical separation so those two bones can wear against the substance and not against each other. Arthrovet has the advantage over hyaluronic acid as it does not degrade over time and thus provides lubrication for a longer period of time. We know with hyaluronic acid we can be doing 6 month or yearly re-injections to keep adding more hyaluronic into that joint, where Armed vet, you can prolong the introduction or between repeated doses.

So a new supplement that's come to the market called Spring, and this works a lot like Arthro Medvet as it delivers a natural inert protein, carbohydrate aggregate to act as a shock absorber. Between the bones and it mimics the matrix material of natural cartilages, and so in this it's protecting and pushing the joint and augmenting, and has almost a complementary function of synovial fluid in the cartilage. New drugs to market, and this is really new and it's exciting.

It's invitin and this is a radioactive tin. So it is a radioactive isotope that we're injecting to the joint and this reduces synovitis and relieves chronic canine pain, and this has been tested in the elbow joint at the moment. It targets pro-inflammatory macrophages and it's very long lasting up to one year.

They're seeing relief from one treatment. And so, this being given every year if needed, and has no synthetic or local side effects, but you're injecting a radio radioactive isotope into that joint, so the animals have to be treated as radioactively contaminated for a week or two, depending on the size of the dog, and there's a whole protocol to this, but this is a really exciting new, Device, not drug that is coming out in the United States that if it proves beneficial and the studies have shown that it's really great for elbow dysplasia, then could be expanded to other joints in the body. So home environment.

And so this is something I want to touch on because this is really important. And so we need to think about betting systems, and this is gonna revolutionise how we treat our patients all the way through their lifespan. They, we shouldn't just be thinking of geriatric dogs getting bedding systems, we should think of puppies all or either through the different stages of their lives because this is going to protect their joints as they go.

Through their life. And the two big bedding systems that I recommend are Big Barker dog bed and underdog orthopaedic beds, and we'll talk about the two different systems and why I recommend them and why these are also gonna be huge, in my practise, huge game changers for how I treat my clients and my pets, or their pets, sorry. So Big Barker dog bed, this is made up of different layers of foam, and this company's developed years to work out different layers that will help support mainly large and giant breed dog joints.

And they did force plate analysis to show that animals aren't now compressing, because we know those traditional dog beds go flat and now their joints are on the floor, and this, as you can see the force plate analysis prevents compression of those joints touching the floor. So here's two photos of the big Barker dog bed. On the left-hand side we have a golden retriever on it, and then on the right-hand side, the covers pull back to show the different layers of foam.

What I'm really excited for a neurological patient is the underdog orthopaedic dog bed, and this is an air mattress that works like a water bed but has fingers. And so distributes the weight and helps cushion our patients. So how does this work?

It works by having a low surface tension. So the weight's evenly distributed, causing maximum comfort. It constantly restores and restoring forces, so it pushes back up.

Has 6 degrees of movement, we'll talk about the fingers, so they move and support and has a low friction and sheer correlation. So it's great for neurological dogs, dogs with DM, dogs with degenerative joint disease, post-surgical dogs, dogs with neurological deficits because it helps support them so they're not getting the pressure and necrosis. And so this is how the system works, so it's all individual air cells that all communicate and allows distribution, almost like a super water bed.

And here's a picture of the 6 degrees of movement of those fingers that help support and move and support the body underneath. Here's an example of their force plate so you can see, without, with their bedding system, there's no point loads and no point load necrosis, and this is the really exciting bit that I'm, as you can tell, really excited, but really, really excited about when it comes to our neurological degenerative joint disease, post-surgical patients. And it's plastic, so it can be washed, washed down, the covers can be changed really easily.

And so here's just another picture of their force plate analysis. Rule of thumb with bedding, here's the two beds, my dog on on the beds when I was doing the trials, always go bigger because you want them to be able to lay down on it and be able to support their joints, not lay half on it, half off it. OK, rehabilitation modalities.

Which rehabilitations to choose for degenerative joint disease? What do you want in your hospital, what do you want to recommend to your clients? So my top five rehabilitation modalities are laser, #1, underwater treadmill, if you have it or you can send your clients to.

But really it should be number 2 or number 1 is pulsed electromagnetic field theory therapy or PEMF. Shockwave therapy and then coming in at 5 therapeutic exercise. So rehabilitation benefits us, reduce pain, eliminates, edoema and swelling and inflammation, improves joint range of motion, prevents scar tissue formation and contracture from tissue atrophy.

Helps build and strengthen muscles, improves muscle mass and helps re-educate and balance and coordinate that we know we lose as we get geriatric disuse injuries. Helps maintain and enhance circulation, improves endurance and conditioning, promotes healing and, and of lesions and soft tissue injuries, helps re-myelinate nerves and nerves fibre of socio neurological or degenerative joint or degenerative myopathy diseases, improves patients' wellbeing and quality of life and enhances the whole pet, Owner bond relationship. So laser therapy uses a single wavelength of light to deliver photons and energy to targeted tissues to create something called photobiomodulation.

That's the big word of the day is photobiomodulation. And so what we're looking at is trying to get laser light to depth prenotation of a tissue so we can get a biological response. So what are the mechanisms of action on a cellular level, and we have that photon energy goes into the cell, stimulates the mitochondria.

That's really the power plant of the cell to bring up more glucose, more oxygen absorbed in to get turned into ATP. And this is the big part is in that reaction we go from cytochrome C to cytochrome C oxygenase, and this is the power of laser. So the photobiological effects cause an uptake of oxygen and glucose to form ATP.

I just talked about that. We now have more nitric oxide synthesis release. We get more oxygen release.

We have modulation of cell signalling, they signal better, they talk better. We have synthesis of RNA and DNA. We have synths of cytokines, growth factors and enzymes of proteins that help protect the joint and stimulate healing, increased blood flow, we have an increase in cell growth or proliferation and migration.

So as I said, so we have 3 classes of labour, class class 4, C class 3B, and class 1. And so, The different higher the levels is just the faster delivery of treatment, so a class 4 will delay, deliver a dose quicker than a class 3B, quicker than a quicker than a class 1. A class 4 has detachable heads and you can use different wattages, has a higher wattage power and can potentially penetrate deeper into cell tissues.

As I said before, class 4 lasers have detachable heads, they have a collimated head and a non-collimated head. So that just means collimated, it shoots a narrow beam, and that narrow beam can target a tissue. A non-collimated means it disperses the beam as the photo.

Here's a collimated, I've put on a ruler, you can see it's really pinpointed, and then a non-coherent or non-collimated spreads that over, so that's great for superficial skin and con and collimated is great for tissue penetration. And here's pictures of collimated and divergent beams to see you can get a good idea. This is dosing, I'll just skip over this side, but there's a list of jewels that you want for different activities to dose.

Class 3 big lasers. This is usually a. LED based technology, so it works in different wavelengths.

Class 4 lasers, lasers work in the infrared spectrum. Class 3B lasers can work in infrared red and blue light spectrum. So they're usually less than 500 milliwatts of power where a class 4.

Is more than 500 milliwatts of power. And once again, this helps accelerate tissue growth and repair, and this increases wound healing, probably about 33%. Pain relief and analgesia with laser therapy.

Greed decreases inflammation, helps with vasodilation improves inflamming drainage. So here we have light pads on a dog. Laser function's also been shown to improve nerve function, axonal regeneration, and neurological repair.

Helps decrease fibrosis, and this is also gonna be used for acupuncture point, both with the class 4 and the class 3B, and a class 1 can be used for accupoint stimulation. Great for trigger point modulation and used for skin infections and burns with a class 3B. So here's a little guy, he suffered.

It's 3rd degree burns when he walked underneath a barbecue just after having invertible disc disease surgery. And so we're using class 3B laser light to stimulate regeneration of the epithelial cells on his back and help bring in epithelial and lessen the chance of scar tissue formation on his back. The laser light spectrum for class 3B, as I said that infrared, red and blue light.

And here's just a diagram showing you the different light. So here's your infrared on the right-hand side, the top, the red, the blue, but the great thing is you can run all three light spectrums at the same time to speed up treatment times. Here's just a little list of what different things can be done with the blue light, the red light, and their infrared light.

So class one lasers, and this is a new category that's come out, and what's really exciting for the vet profession is we can send these lights or lasers home with our clients. You don't need protective glasses, you can give these to clients and they can do laser treatment at home. You can rent these devices and also build revenues for the practise while your clients are treating their pets at home.

Class 1 lasers are usually less than 5 milliwatts of power. They usually have a pulsing laser cycle, they're LED based technology. And they help accelerate tissue repair and growth, create faster wound healing, pain relief, decrease inflammation and vasodilation, and improve lymphatic drainage just like their big brother counterparts.

They also come in red and blue lights you can use it for superficial and also look for getting deeper tissue treatment. So cold laser therapy, once again, biomodulation, great for treating soft tissue trauma and mainly with tendons and ligaments or muscle blunt force trauma, promotes healing of stretched tendons and ligaments, increases wound healing and tissue healing times by about 33%. Increases speed, quality of tissue strength and tensile strength after an injury.

Also decreases musculoskeletal pain and inflammation. Relieve stiffness and pain in joints and muscles associated with compensatory issues, assists muscle and nerve regeneration, treats arthritis, relieves pain, increases range of motions and reduces swelling associated with soft tissues, and decreases edoema. Hide your therapy, this is great if you have it in your clinic, you can put it in your clinic or have where somewhere to send your clients to, underwater treadmill is one of my go to modalities.

And it works many muscle groups at the same time. So it decreases post-surgery injury recovery times and minimise post exercise muscle soreness, provides resistance because they're moving through water that creates a 1 to 4 resistance as if they were on land, so they can do what they can do in 5 minutes, usually is a 20 minute workout on land they can do in 5 minutes. And it's a great closed chain hydrokinetic exercise.

The warm water assists with pain reduction, incredible for geriatric patients because they have buoyancy, they can move in a free environment, decreases the risk of overheating and the water height can be changed to help stimulate, create more resistance or less resistance as needed. This is really good for neurological patients if we can get in there and help re-myelinate and move, also with degenerative joint disease, disuse, muscle atrophy, great to be in. Here's a photo of myself.

It was, party day, so we get dressed up with the duckies and the treadmill and we're in there helping these neurological patients after intervertebral disc disease surgery. Deepwater therapy, people ask this question, great for weight management, conditioning, neurological conditions, but I always say this should be done at a facility where you have a trained rehab professional in there with the patient swimming with them all the time managing. If you don't have access, ponds, dams, here's a photo at the bottom of my or at the top of my dog Nalu, swimming in, a stream, so we're getting that resistance, and you can bring her in and out from the shore to do depth.

And then here's my beloved Tova when she had degenerative myopathy, and we're in the Sydney harbour and we're swimming her up and down the beach. Pulsed electromagnetic field therapy or PEP, this is really my go to now on par with laser therapy. What the studies showed of this technology is pretty incredible.

Decreases swelling and inflammation associated with soft tissue trauma and surgical wounds. Accelerates bone healing times and alleviates bone fractures, relieves pain associated with osteoarthritis, improves recovery times associated with eugenic joint disease, and accelerates tendon and ligament damage healing times and recovery times with no scar tissue formation. So here are a few things that PE can be used for osteoarthritis, go to it's fantastic degenerative joint disease in any joint, tendon and ligament damage, soft tissue trauma, and wound management, bone, non-union or bone fracture healing.

In their original stay, they took a little piece out of a rabbit on either side of the ulna, they took a 1 centimetre wedge out. 21 days this was controlled, this had the pimp treatment. This bone, 1 centimetre was totally rehealed, calcified in, you couldn't see it.

This side, the control still had the wedge missing, so it's that powerful for bone healing and great for intervertebral disc disease patients. Two companies out there, you have KVP Cura that have a disc and the disc attaches to a Velcro suit, or you have the CC loop and they have the loop and a bedding system. Here is a photo of the Assisi loop bed or lounge, and I'm in the middle of a study, with this, and it is fantastic what it is doing for geriatric patients, and then you also have the Assisi loop.

The KVP Curer just comes in the frisbee, it's very much like the CC loop, and that can be targeted to different joints on the body when they're wearing that vest. Shockwave therapy has had a re-emergence. I'm so excited now about this new technology, or it's old technology being able to be used in new ways.

So everyone will probably remember this old device you needed to sedate the animal to do shockwave therapy because it hurt. Now we have new technology, it doesn't hurt anymore, and it's opening up how we can do treatment for our patients. So the two companies are Pulsevet and Pizzo Wave, the two companies out there with non-painful treatment options now when it comes to shockwave therapy.

So what does shockwave therapy do? It improves blood supply, accelerates tissue regeneration. Accelerates bone repair because it stimulates the the bone to stimulate an inflammatory cascade to help non-union fractures heal, and accelerates tendon repair.

So this is just a picture of the diode, and this is, you can see the wavelength coming out and how it heats up. So Pulsevet is one of the companies, and it's been out a long time and they've re-engineered their heads. So now this works through a pulse wave, and you can go tat tat tat tat tatt sounds like a machine gun.

And that sent a sound wave every time and it was felt like a rubber band being slapped against you, and it really hurt. And that's why we needed to sedate our patients. Now with this new head that they've designed, it feels like a little tapping.

You still feel something but it's a sound wave, but it feels like a tapping. It's no longer a noxious stimulus and that's really exciting for this product. Pizzo wave, this is another company, but this works through like a soft tissue ultrasound.

It creates an electric current through crystals that then create a wave, so you don't feel this at all. And so this isn't a great machine. It has different header applicators for different focal depths of penetration.

It also has these silicon cups that go onto the electrodes so you can treat pinpoint or a wider area. And so these two are now. Have revitalised the shockwave therapy because now it's not painful, we can do so much and this is great for soft tissue wound stimulation.

It has multimodal approaches for the treatment of different conditions. I'm so excited about this new resurgence of an old technology. So let's talk about therapeutic exercise.

This is the 5th on my chart, and here's an example of an exercise chart that clients get with our programmes, so they get to tick off as they're doing the exercises with their pets during the day. And so why we want to do strategic exercises, because they help build and maintain core muscle strength, helps the patient stay active, helps slow down the development of degenerative joint disease, so they have a better quality of life and they feel more comfortable, but also builds that patient pet bond. Equipment, this is just a list I'm gonna jump over of pieces of equipment that can be used for therapeutic exercises.

And therapy exercises helps with proprioception and weight shifting, and so they're used to help pets shift their weight from their front limbs or side to allow proprioception so they know where their pets are in poor, their weight balance because we know with degenerative joint disease, if it's, Bilateral or unilateral, they're weight shifting off compensating, and so this allows them to now be loading those joints, we know through Wolf's law, we need to load those joints to get inflammatory cascade going out. The sponge effect in cartilage brings in nutrients, expels excess waste products. We need all of this and therapeutic exercises allows us to do that.

Helps with strengthening exercises, so we're helping those individual muscle groups, or muscle groups in a whole, to build strength, build coordination and build you use, because we know the catchphrase is motion is lotion. So let's talk about weight loss, because this is really important when we're talking about anything to do with osteoarthritis. We know that approximately 38% of all adult dogs out there are overweight.

Middle aged dogs goes up to 50% or over 50%. And this is overloading our joints. And so we know that for every 1 pound of excessive weight or every 1 kilogramme of excessive weight equates to 4 pounds or 4 kg of additional sheer force going through that joint, and that was a human study done.

So if we use an overweight Labrador for example, that's 10 pounds or 10 kg overweight, I, I'm bad with numbers, so 10's an easy number. It means it's 40 pounds or 40 kg of additional sheer force going through that joint. So the most important thing we can do for our clients is to get them to lose weight.

And then we can get them off nutraceials, we can get them off supplements, but if we can get them to lose weight, that is the hardest thing, but also the most rewarding thing we can do for our patients. Regenerative medicine, we're almost there. We've got a few more minutes, I'm coming up to the hour.

I know I've been going super fast and I apologise, but I wanted to give you the framework so you can get these tools, information to start thinking about incorporating this into your treatment plans for your patients. So regenerative medicine, all about promoting blood supply, helping breakdown existing scar tissue formation, regeneration or rejuvenating new tissue so they become scar free. Best chance of returning in tendons to their existing tensile strength, because we know tendons are fibres, when they get disrupted or injured they form this big mass and they form the scar tissue that's not as strong as the original tendons.

But if we can get it to form back to how it was, we now can regain most of the tensile strength of what was before injury and that prevents future re-injury. So the three things for regener medicine are stem cells, PRP or platelet-rich plasma, or combination of both. Here on the right-hand side is an image of PRP that was getting ready just before injection.

So let's talk about stem cells because stem cells are the big daddy, the big catch phrase for what people think when we think of regenerative medicine. So, stem cells will use the dog's own adult mesenchymal fat cells or bone marrow derived stem cells in this treatment. And these stem cells can be given either intravenously, inarticularly, or into tendon, depending if it's a soft tissue, a hard tissue or a systemic issue that we're trying to regulate.

Now in the next 1 to 2 years, we're going to get, And I always can never pronounce this. A here we go. We could say stem cells that can sit on the shelf, we no longer need to harvest stem cells.

They're allergenic stem cells. There we go. I'll give myself a pat on the back.

So these antigenic stem cells can now be ordered and injected straight into the body, the soft tissue, intravenous, and we no longer have to wait for tissue harvesting and tissue manufacturing, and this will change how we look at regenerative medicine. Also, mechanisms of actions, they're incredible anti-inflammatory. They have essential mediated analgesia pain relief.

They increase blood supply to the area. We know with increased blood supply, we get more nutrients coming in, we get edoema, bruising, and everything moving out, lymph moving out, that speeds up tissue healing times. And so that enhances tissue repair and regeneration and also it's been shown to kickstart the inflammatory cascade process.

So here we have photos of harvesting, so we harvest from the thoracic wall because some dogs will have had surgery and had the adipose tissue or the fatter falciform ligament removed. So on the right-hand side, this is removing a falciform tissue from the abdominal cavity and you go and you go. Oopsy, it's already been removed the time of spa because surgeons will just get rid of it so they get good surgical margins to look for the uterus and the uterine horns.

But so we will go and we do the thoracic wall, but this is a thing of the past because hopefully in a year, we will no longer need to do these surgical procedures. So, stem cell therapy are great to mild to severe cases. Because of the collection methods, we have to have the mesenchymal adipose derived tissue or the bone marrow derived tissue.

Processing can either be off-site, and that can take 3 to 5 days or on-site and on the right-hand side is a photo of the companion on-site processor, and that is done in the same day. So let's talk about PRP or platelet rich plasma. So plate-rich plasma has an inhibitory effect on the inflammatory cascade and can be used in the treatment of osteoarthritis or other soft tissue injuries, exactly the same as stem cells, it's just, I call it the poor cousin to stem cells.

In platelet rich plasma, we're working off the growth factors of the platelets to stimulate the inflammatory cascade again, where with stem cells we're working off the stem cell regeneration factor that's coming in with that treatment. So what is PRP? So PAP is concentrated platelets and growth factors, and so the mechanism of action is, We see collagen regeneration that is also a cyst in tendon and ligament repair.

They cause the inflammatory cascade to be retrigger so we get that whole re triggering of the inflammatory cascade. So on the right-hand side, these so what we do is we draw out blood. Depending of the size of the animal, it can be 20 to 50 mLs.

We put that into a test tube, it's spun down in a special centrifuge, and then you get this separation, so above the yellow is the plasma. Down below is the red, is the red blood cells, and then you have this little grey cloudy material here, the arrows point to, and that is your PRP or concentrated platelet. It is great for centrally mediated analgesia, that gives pain relief, increases blood supply to the area, speeds up tendon ligament healing, repair regeneration just as I said before in the previous slide, but also in the stem cell slides.

So here are two PRPs drawn up, ready for injection. So now we wanna do is combine PRP with stem cells, really they have a synergistic effect and as we're pulling up the stem cells or harvesting stem cells, when they come back in we can pull blood, spin it down, get the PRP and inject those together. And they can both be given intravenously intratendon or intra-articular.

And this is the big thing people ask, how long does it take before I see results, and sometimes it can take up to 90 days to see results with either PRP or stem cells. So we're right on an hour. I got us there.

Oh, I know I have gone fast. I've tried to give you as much information as I said previously, because I was asked this whopping big question about surgical and non-surgical approaches or things we can do for osteoarthritis. So hopefully that's given you some tools, some things to think about.

If you have any questions, send them to the webinar vet and I'll be answering those questions, but also send questions to support at veterinary Teaching academy.com if you have questions about this or other things that I've talked about. I really encourage you if you want more information, go to veterinary Teaching Academy.com or go to canine Rehab on Demand.com to see the programmes that we have that we've developed now to help veterinarians help their clients, education, the consultation room, but also help.

Clients do rehabilitation with their pets at home. We're about to launch a whole post-surgical programme. So veterinarians are now prescribing programmes after surgery, so orthopaedic soft tissue, so clients go home now, they're being up serviced with programmes, and we're doing a lot of really exciting things in this year.

So I encourage you if you want to learn more information, go check out our our two websites. But I wanna thank the webinar vets for giving me the opportunity to come and hopefully you've learned something on this webinar, and you'll be able to put that into practise in your consultation room, your clients will love you and your patience at the end of the day will be the winners and it's all about education. So once again, thank you very much.