What is multi-modal therapy and how is it used to manage osteoarthritis pain?
Multi-modal therapy for osteoarthritis (OA) refers to using a combination of treatments to target different aspects of pain and joint degeneration. For many years, OA in dogs was treated primarily with non-steroidal anti-inflammatory drugs (NSAIDs). However, over time, it has become clear that NSAIDs alone are often inadequate for OA pain relief.
Pain research has advanced, and now suggests that a better choice for managing OA is an integration of multiple different therapies that target different aspects of the disease, including (but not limited to) pain relief (often NSAIDs), weight loss, controlled physical activity, nutrition, and modifications to the home environment.
Multi-modal therapy recognizes that OA is a progressive and complex condition, and so a single approach is often not enough to effectively manage pain and maintain a good quality of life.
What role do NSAIDs play in multi-modal OA pain management?
NSAIDs are just one of the options used in multi-modal OA pain management. NSAIDs provide anti-inflammatory and pain-relieving effects that target affected joints, helping restore function. NSAIDs are the cornerstone of pain management in OA patients who can take them safely.
"It is essential to evaluate a dog’s overall metabolic profile with bloodwork (especially liver and kidney function) to confirm that administering an NSAID is appropriate."
It is essential to evaluate a dog’s overall metabolic profile with bloodwork (especially liver and kidney function) to confirm that administering an NSAID is appropriate.
Once a full multi-modal pain management plan is in place, your veterinarian may be able to lower the NSAID dose to minimize the risk of an adverse event, and to reserve a full, therapeutic dose for any acute inflammatory pain event (e.g., surgery, sprain/strain, laceration). Some dogs with OA who receive multi-modal therapy can cease their use of NSAIDs altogether.
What other treatments are typically included in a multi-modal therapy plan for OA?
Your veterinarian will tailor your dog’s OA treatment plan to their specific needs. There are many tools your veterinarian can use for multi-modal therapy, including:
- Joint supplements and nutraceuticals (e.g., glucosamine and chondroitin sulfate, omega-3 fatty acids, Cartrophen Vet)
- Nutrition (e.g., Hill’s® Prescription Diet® j/d®, Royal Canin® Advanced Mobility Support)
- Weight loss
- Adjunctive medications
- Bedinvetmab (Librela®)
- Physical medicine (e.g., physiotherapy, chiropractic, acupuncture, acupressure)
What role do joint supplements and other nutraceuticals play in multi-modal therapy or OA management?
Joint supplements and nutraceuticals provide poly-sulfated glycosaminoglycans (PSGAGs) to dogs with OA. PSGAGs are the “building blocks” of cartilage. PSGAGs heal micro-injuries to the cartilage, and so have an indirect anti-inflammatory effect, contributing to pain relief. These products help support the joint and may be injected or taken orally. Your veterinarian can prescribe the most appropriate products for your dog.
It is important to choose products that have been evaluated in clinical studies and determined to be effective. See handouts “Joint Support and Disease-Modifying Osteoarthritis Drugs (DMODADs) in Dogs” and “Nutraceuticals for Joint Support in Dogs with Osteoarthritis” for more information.
How can nutrition help a dog with OA?
The first nutritional step for a dog with OA is weight normalization. In fact, weight loss in overweight dogs with OA has been proven to contribute significantly to pain relief. It is important to consult with your veterinarian about creating an appropriate nutrient profile to help your dog lose weight. Simply reducing the dog’s portion of maintenance food can cause malnourishment.
Once weight and body composition are normalized, it is then important to use a nutrient profile that has been proven in clinical studies to help manage OA. Diets containing omega-3 fatty acids have been clinically proven to help reduce inflammation. Your veterinarian is your best source of guidance when choosing the most appropriate nutrition for your dog with OA.
What adjunctive medications are used in multi-modal therapy plans?
Several other medications have been used to complement NSAIDs in multi-modal therapy plans for canine OA:
- Amantadine (brand names: Symmetrel®, Gocovri®, Osmolex ER®, Endantadine®)
- Gabapentin (brand names: Neurontin®, Aclonium®, Equipax®, Gantin®, Gabarone®, Gralise®, Neurostil®, Progresse®)
- Bedinvetmab (brand name Librela®)
Bedinvetmab (Librela®) is a new option, now available in many countries. It is given by your veterinarian as a once-a-month injection under the skin. It is a type of medication called a monoclonal antibody. Antibodies bind to and inactivate different substances. This antibody binds to a protein called nerve growth factor (NGF), disrupting the transmission of pain signals, decreasing inflammation, and helping prevent increased pain sensitivity. This medication is shown to be effective, with minimal side effects. Long-term studies of using NSAIDs and Librela® together have not been done yet; however, many dogs can be transitioned from an NSAID to Librela®.
What is physical medicine?
Physical medicine is any therapy that involves your veterinarian addressing the tissues directly with their hands. Needle work might be used (acupuncture or trigger point release), and spinal manipulation may be recommended (chiropractic techniques). Physiotherapy/rehabilitation encompasses a broad scope of physical medicine that may include therapeutic laser, joint mobilization, medical massage, stretching, therapeutic exercise, and hydrotherapy, among others. A trained rehabilitation practitioner will create the most appropriate treatment plan based on the needs of the individual dog.
Can I make changes around my home to support my dog?
The supportive care required for dogs with OA will vary, depending on their level of function and their living environment. The following supportive care options apply to most canine patients living with chronic pain from OA:
- Raised food and water dishes. Dishes placed at a level between the dog’s elbow and shoulder allow them to eat and drink while keeping their spine in a “neutral” position. This position decreases strain on the lower back.
- Restricted access to stairs. Many dogs with joint or back pain from OA experience weakness or decreased balance. It is a good idea to protect these dogs from unsupervised access to stairs. Baby gates work well for this purpose.
- Non-skid floor surfaces. Dogs with OA pain need to walk without worrying about their feet sliding out from under them. Use non-skid area rugs in high traffic areas with slick floors or interlocking foam tiles like the ones used in day care centers and work-out gyms. Foam tiles are easy to install, easy to remove, and easy to clean.
- Assistive devices. Some dogs with OA do best with the occasional helping hand, such as a fabric sling or a Help ‘Em Up Harness®. Wheelchairs like the K-9 Cart® can be considered in certain situations.
The key to understanding multi-modal therapy for dogs with OA is to appreciate that there is no single “magic bullet”. A multi-modal treatment plan acknowledges that OA is a complex disease that requires a complex approach. Multiple modalities work together better than one modality can work on its own.
Your veterinarian can choose treatments that will best manage your dog’s OA. Every multi-modal treatment plan is tailored to meet the needs of the individual patient and then adjusted as treatment progresses.
