Complementary Pain Management in Companion Animals

B. Duncan X. Lascelles, BVSc, PhD, DACVS: Let me just move onward from the drugs a little bit. Sheilah, talk about complementary therapies. And I’d also like to maybe touch on therapies that don’t necessarily address the pain directly, but help with function. How would you prioritize complementary therapies that we have available to us?

Sheilah Robertson, BVMS, PhD, DACVAA, DACAW: When we talk about acupuncture, I don’t think that always has to mean that the cat or the dog has to visit an acupuncturist or someone who’s trained in that area. I think we need to be better at teaching our owners how they can actually do some of these physical therapies, massages, and so on at home. Owners could be taught to do passive range of motion, which might be very helpful. The positive benefit of that is if you teach them to do that with their pet, you’re increasing the time they spend together. That maintains the bond that might be getting broken, like Margaret said, in consequence of the medication or the burden that they have of worrying about their pet. So, involving them in the treatment is essential to maintain that bond. And if you think about what we do with people, if you can increase how interesting your day is, then you may focus less on your pain. And so, we should be teaching them about enrichment and things that they can do. We can teach basic therapeutic massage to owners. We can teach them to feel for that little knot in their cat or dog’s back and work on it a little bit. I think there’s a lot we can, and, again, that would decrease the cost burden also on the owner as well and increase their bond.

Grooming a cat with OA, because they can’t groom themselves very well sometimes, probably has positive effects on mood. We know that from humans, different hormones are released when you get a massage or someone grooms you. I think with all of these things, we can put them together. We don’t have a lot of evidence, but it’s a good way to at least be pushing the owners in that direction, I think.

B. Duncan X. Lascelles, BVSc, PhD, DACVS: You would say that acupuncture, massage therapy, basic hygiene, grooming, and passive exercise are maybe…

Sheilah Robertson, BVMS, PhD, DACVAA, DACAW: Enriching the environment. We talked about how chronic pain can lead to anxiety or depression, and that’s probably true in all species. So, a lot of the treatments for that would be engaging the animal in something more positive.

B. Duncan X. Lascelles, BVSc, PhD, DACVS: How would you assess the impact of these therapies that are maybe not necessarily directly addressing pain? Do we assess the impact in the same way with the tools that we have for assessing function and disability?

Sheilah Robertson, BVMS, PhD, DACVAA, DACAW: We don’t really have those tools. We’re working on the cognitive tools. I think that’s going to be really important when we have the really good cognitive tools to assess how much chronic pain impacts cognitive dysfunction. We’ve always talked about old dogs that get cognitive dysfunction, but I think we’ve never really strongly linked it to, maybe, pain.

Mark Epstein, DVM, DABVP, CVPP: Even though it is in humans.

Sheilah Robertson, BVMS, PhD, DACVAA, DACAW: It is in humans. We’ve always thought it’s brain degeneration. We know there’s a decrease in neurotransmitters. We know everything alters. And, of course, there’s lots of therapy. We should be using more antioxidants. We should be using “this.” But, I think the connection between long-term pain and cognitive dysfunction is somewhere. I think it’s going to be really fascinating to see that connection. And as we’re talking about addressing the early OA, maybe we’ll find out that cognitive dysfunction is better later because we dealt with the disease at an earlier age.

B. Duncan X. Lascelles, BVSc, PhD, DACVS: We’re going to need the tools to make an assessment.

Sheilah Robertson, BVMS, PhD, DACVAA, DACAW: We need the tools.

B. Duncan X. Lascelles, BVSc, PhD, DACVS: So, we’ve moved from discussing nonsteroidals to talking about adjunctive drugs and complementary therapies. Bryan, will combinations of these adjunctive drugs, adjunctive therapies, or complementary therapies replace the need for an effective analgesic, such as the nonsteroidals and the piprants?

Bryan T. Torres, DVM, PhD, DACVS-SA, DACVSMR: No, not that I foresee in the near future. I don’t think so. I think that’s going to be our foundation for quite some time. In the far-off future, that that may change, but I don’t know. But I think the inflammatory process, as far as osteoarthritis goes in treating with a nonsteroidal, is critical—critical early, critical late. I think it’s critical.

B. Duncan X. Lascelles, BVSc, PhD, DACVS: So, we see a very important place for these complementary therapies, but we still agree that there’s a need for an effective, predictably efficacious analgesic?

Bryan T. Torres, DVM, PhD, DACVS-SA, DACVSMR: Yes.

Mark Epstein, DVM, DABVP, CVPP: At its core, osteoarthritis is an inflammatory disease, and nonsteroidals and the piprant class have the ability to reduce the inflammation. But, they can also help to mitigate some of the central sensitization and peripheral sensitization that goes with it. That’s why I will echo Bryan. For the foreseeable future, it will be a foundation.

B. Duncan X. Lascelles, BVSc, PhD, DACVS: Well, thank you very much, everyone. This has been a fascinating, interesting discussion. I just want to finish up by asking each of you for your final thoughts.

Mark Epstein, DVM, DABVP, CVPP: Well, thank you Duncan. It has been great to sit on this panel with this esteemed group. It has been an honor, and I hope it will move the conversation forward—not just here, but out in the field and along with our colleagues.

B. Duncan X. Lascelles, BVSc, PhD, DACVS: Margaret, your final thoughts?

Margaret Gruen, DVM, MVPH, PhD, DACVB: I echo that. It has been wonderful to be a part of this panel, and to bring such a diverse group of experience and viewpoints in together. I’m excited about the future and the new developments in therapies and the new avenues that we’re looking at with cognitive dysfunction and in managing the whole environment. I think it’s a really exciting and important time.

B. Duncan X. Lascelles, BVSc, PhD, DACVS: Sheilah?

Sheilah Robertson, BVMS, PhD, DACVAA, DACAW: I just have to say the same as everybody else. It has been fascinating, and I think the future is very hopeful and bright for dealing with chronic pain in all species. It’s going to be exciting times, I think.

B. Duncan X. Lascelles, BVSc, PhD, DACVS: And Bryan, last but not least?

Bryan T. Torres, DVM, PhD, DACVS-SA, DACVSMR: I think that’s it. I echo everybody’s statements here. I’m excited to see where we move in the future. I’m excited to see where this goes.

B. Duncan X. Lascelles, BVSc, PhD, DACVS: Well, thank you. Thank you very much. Thank you all, again, for your contributions to this discussion. And, on behalf of our panel, we thank you for joining us and hope that you have found this American Veterinarian^® Peer Exchange to be useful and informative.