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Probiotics, the missing nutrients — part 2

A balanced intestinal microbiome is crucial to good health in dogs and cats, as well as in humans. Probiotics can play an important role in maintaining this balance.

In Part 1 of this series (IVC Journal, Spring 2018), we looked at the discovery of probiotics along with research documenting the importance of a balanced intestinal microbiome. We discovered how many modern medical practices can disturb the balance of gut bacteria in an unhealthy way, and the role probiotics play in mitigating dysbiosis and maintaining intestinal lining integrity. In Part 2, we will explore more detailed research on the health benefits of probiotics.

Probiotic effects on healthy pets

Probiotic supplementation can have beneficial effects on healthy animals. In one study, dogs were given probiotics for seven days. Even though the administered strains disappeared within a week after discontinuation, there was a sustained change in the population of indigenous lactic acid–producing bacteria in jejunal contents, with native L. acidophilus strains predominating.1 In another study where dogs were supplemented with L. acidophilus, an associated increase in the numbers of fecal lactobacilli, along with a decrease in clostridial organisms, was observed. Furthermore, there were significant increases in RBCs, HCT, hemoglobin concentration, neutrophils, monocytes and serum IgG,  and reductions in RBC fragility and serum NO2Supplementation of puppies with Lactobacillus caused an increase in appetite and food intake, which led to higher daily weight gain.3 When 15 healthy cats were supplemented with L. acidophilus, populations of fecal bifidobacteria, Clostridium spp and Enterococcus faecalis, decreased. Granulocyte phagocytic activity and eosinophil numbers increased, while erythrocyte fragility and plasma endotoxin concentrations decreased.4 Other researchers found that “Feeding studies with a Lactobacillus acidophilus probiotic have shown positive effects on carriage of Clostridium spp. in canines and on recovery from Campylobacter spp. infection in felines. Immune function was improved in both species.”5]

Probiotics and GI disease

Studies show that chronic GI issues, such as inflammatory bowel disease (IBD), are associated with alterations in the microbiome. There are consistent decreases in Firmicutes and Bacteroidetes and increases in Proteobacteria species. These changes lead to susceptibilities in the innate immune system of dogs and cats with IBD.6 Other research confirms there is a predictable pattern of dysbiosis in dogs with various GI diseases, and that the bacterial groups commonly decreased are those considered to be important short-chain fatty acid producers.7 This is important because short-chain fatty acids are needed to maintain the health of enterocytes.

Probiotics and the immune system

The gut associated lymphoid tissue (GALT) makes up 70% to 80% of the body’s immune system. This means the GI tract is the largest organ of the immune system. Multiple studies show that probiotic supplementation can affect the systemic immune system in many ways. When puppies were given the probiotic E. faecium SF68 from weaning to one year of age, their serum IgA concentrations were higher, they had a greater proportion of mature B cells, and they had higher titers after distemper vaccination than control puppies.8 Also, several studies in humans show that probiotics can prevent and/or treat food and atopic allergies.9,10 A study in dogs found that when puppies were given a probiotic supplement before the age of six months, they had decreased allergen-specific IgE and reduced development of atopic dermatitis in the first six months. A three-year follow-up with an allergen challenge demonstrated a low IL-10 for all allergens in probiotics-exposed dogs.11 Other researchers concluded: “Many studies have found that gut microbes are involved in the immunopathogenesis of Diabetes Mellitus. Probiotics strengthen the host's intestinal barrier and modulate the immune system….”12

The microbiota-gut-brain axis

An aspect of the microbiome that is often overlooked is its effect on the brain. One study found that the microbiomes of patients with major depressive disorder (MDD) differed significantly from those in healthy controls. When the microbiomes of MDD patients were transplanted into germ-free mice, the mice displayed depression-like behaviors. To the contrary, when germ-free mice were transplanted with microbiomes from healthy patients, there was no behavior change. “The gut microbiome is an increasingly recognized environmental factor that can shape the brain through the microbiota-gut-brain axis.…” concluded the researchers. “This study demonstrates that dysbiosis of the gut microbiome may have a causal role in the development of depressive-like behaviors, in a pathway that is mediated through the host's metabolism.”13 No doubt, dysbiosis plays a role in canine and feline behavioral issues. One way the microbiome affects the brain is the fact that certain intestinal bacteria produce and deliver neuroactive substances such as serotonin and gamma-aminobutyric acid (GABA). “Preclinical research in rodents suggested that certain probiotics have antidepressant and anxiolytic activities.”14 In addition, three double-blind, placebo-controlled trials studied the effect of probiotics on the stress responses in healthy medical students before exams. They found that probiotics may reduce stress reactivity in the paraventricular nucleus through vagal afferent signaling.15 Another study found that chronic administration of probiotic L. rhamnosus (JB-1) to mice caused a reduced level of anxiety and depression-like behavior. The probiotics induced changes in the GABAergic system in regions of the brain known to involve these behaviors. The researchers further found that a vagotomy prevented the effects of the probiotic, confirming the vagal signaling theory.16

Probiotics and the urinary tract

In a recent study, five lactobacillus strains (L. gasseri, L. rhamnosus, L. acidophilus, L. plantarum, L. paracasei,) were tested in vitro against four uropathogens common in infantile urinary tract infections. All the Lactobacillus strains showed moderate antimicrobial activities against the uropathogens.21 An intriguing case-controlled study involved the ingestion of fermented milk products in Japan. The researchers concluded: It was strongly suggested that the habitual intake of lactic acid bacteria reduces the risk of bladder cancer.”22

Probiotics and mutagen detoxification

In an early study of fermented milk products, 11 healthy subjects were put on a standardized diet that included consuming fried beef patties twice daily. For the first three days (Phase 1), the subjects were given Lactococcus (non-probiotic) fermented milk. During Phase 2, the subjects drank L. acidophilus fermented milk. The total fecal and urinary mutagen excretion (a cancer-causing chemical that is, or has been, excreted in the urine) on Day 3 during Phase 2 was 47% lower compared to Day 3 of Phase 1, indicating the possible role of probiotics in preventing cancer.23

Probiotics as nutrients

According to Stedman’s Medical Dictionary24 a nutrient is “a constituent of food necessary for normal physiologic function.” The term “essential nutrients” refers to “nutritional substances required for optimal health. These must be in the diet, because they are not formed metabolically within the body.” In my opinion, given the research explored in this article, probiotics meet these definitions. I am not alone in my assertion. “The health and well-being of companion animals, just as their owners, depends on the gut microbes…. Specific probiotic strains and/or their defined combinations may be useful in canine and feline nutrition, therapy, and care.”25 Probiotics are essential nutrients for dogs and cats that are not contained in conventional diets, and must be supplemented regularly throughout life in order to maintain or regain health.

Microbiome and obesity

The metabolic activity of the microbiome is especially demonstrated by its effect on fat accumulation in the body. One study utilized four sets of human twins, one of whom was obese and the other lean. When a fecal transplant of the “lean” bacteria was made into germ-free mice, the mice remained thin. However, a fecal transplant of the “obese” bacteria into germ-free mice resulted in obese mice. Moreover, obese mice became thin when housed with thin mice apparently due to coprophagia.17 Another interesting study found that fecal transplants from conventionally raised mice into germ-free mice resulted in a 60% increase in body fat content and insulin resistance within 14 days despite reduced food intake. According to the researchers, “Our findings suggest that the gut microbiota is an important environmental factor that affects energy harvest from the diet and energy storage in the host.”18

Probiotics and pancreatitis

A randomized, double-blind, placebo controlled trial in human patients with acute pancreatitis found that “Supplementary L. plantarum 299 was effective in reducing pancreatic sepsis and the number of surgical interventions.”19 A similar study in dogs looked at experimentally-induced severe pancreatitis and compared ecoimmunonutrition, parenteral nutrition, and elemental enteral nutrition. (Ecoimmunonutrition refers to the feeding of L. plantarum-containing formula.) The probiotic treated dogs experienced lower levels of increase in serum amylase, ALT, AST, and plasma concentrations of endotoxin. They also had suppressed pancreatic and ileal histopathologic changes. Bacterial translocation was also decreased in the probiotic treated dogs.20

Conclusion

We have seen that a well-balanced microbiome with numerous, diverse bacteria is important to an animal’s health. We have also explored the many commonly-used modern medications that can disrupt a pet’s GI bacterial equilibrium, leading to dysbiosis and leaky gut. And now we know how the use of probiotics can improve the health of well animals and effectively address a multitude of diseases. Probiotics truly are the missing nutrients in the diets of our dogs and cats. 1Manninen TJK, et al. “Alteration of the canine small-intestinal lactic acid bacterium microbiota by feeding of potential probiotics”. Appl Environ Microbiol. 2006;72(10):6539-6543. 2Baillon M-LA, Marshall-Jones ZV, Butterwick RF. “Effects of probiotic Lactobacillus acidophilus strain DSM13241 in healthy adult dogs”. Am J Vet Res. 2004;65.3:338-343. 3Pasupathy K, Sahoo A, Pathak NN. “Effect of lactobacillus supplementation on growth and nutrient utilization in mongrel pups”. Archiv für Tierernaehrung. 2001;55(3):243-253. 4Marshall-Jones ZV, Baillon ML, Croft JM, et al. “Effects of Lactobacillus acidophilus DSM13241 as a probiotic in healthy adult cats”. Am J Vet Res. 2006;67:1005–1012. 5Rastall RA. “Bacteria in the gut: friends and foes and how to alter the balance”. J. Nutr. 2004;134:2022S-2026S. 6Honneffer JB, Minamoto Y, Suchodolski JS. “Microbiota alterations in acute and chronic gastrointestinal inflammation of cats and dogs” World J Gastroenterol. 2014;20(44):16489-97. 7Suchodolski JS, et al. “The fecal microbiome in dogs with acute diarrhea and idiopathic inflammatory bowel disease”. PLoS One. 2012;7(12):e51907. 8Benyacoub J, Czarnecki-Maulden GL, Cavadini C, et al. “Supplementation of food with Enterococcus faecium (SF68) stimulates immune functions in young dogs”. J Nutr 2003;133:1158–1162. 9Majamaa H, Isolauri E. “Probiotics: a novel approach in the management of food allergy”. J Allergy Clin Immunol. 1997;99(2):179-185. 10Kalliomäki M, et al. “Probiotics and prevention of atopic disease: 4-year follow-up of a randomised placebo-controlled trial”. Lancet. 2003;361(9372):1869-1871. 11Marsella R, Santoro D, Ahrens K. “Early exposure to probiotics in a canine model of atopic dermatitis has long-term clinical and immunological effects”. Vet Immunol Immunopathol. 2012;2:185–189. 12Wang F, Zhang C, Zeng Q. “Gut microbiota and immunopathogenesis of diabetes mellitus type 1 and 2”. Front Biosci (Landmark Ed). 2016;21:900-6. 13Zheng P, et al. “Gut microbiome remodeling induces depressive-like behaviors through a pathway mediated by the host's metabolism”. Mol Psychiatry. 2016 Jun;21(6):786-96. 14Evrensel A, Ceylan ME. “The Gut-Brain Axis: The Missing Link in Depression”. Clin Psychopharmacol Neurosci. 2015;13(3):239–244. 15Takada M, et al. “Probiotic Lactobacillus casei strain Shirota relieves stress‐associated symptoms by modulating the gut–brain interaction in human and animal models”. Neurogastroenterol Motil. 2016 Jul;28(7):1027-36. 16Bravo JA, et al. “Ingestion of Lactobacillus strain regulates emotional behavior and central GABA receptor expression in a mouse via the vagus nerve”. Proc Natl Acad Sci U S A. 2011;108(38):16050-16055. 17Ridaura F, et al. “Gut microbiota from twins discordant for obesity modulate metabolism in mice”. Science, 2013; 341(6150):1241214. 18Bäckhed F, et al. “The gut microbiota as an environmental factor that regulates fat storage”. Proc Natl Acad of Sci U.S.A., 2004; 101(440;15718-15723. 19Olah A, Belagyi T, Issekutz A, et al. “Randomized clinical trial of specific lactobacillus and fibre supplement to early enteral nutrition in patients with acute pancreatitis”. Br J Surg. 2002; 89:1103-1107. 20Xu GF, Lu Z, Gao J, et al. “Effect of ecoimmunonutrition support on maintenance of integrity of intestinal mucosal barrier in severe acute pancreatitis in dogs”. Chin Med J. 2006; 119:656-661. 21Shim YU, Lee SJ, Lee JW. “Antimicrobial activities of Lactobacillus strains against uropathogens”. Pediatr Int, 2016; Feb 10. Doi: 10.1111/pet.12949. 22Ohashi Y, et al. “Habitual intake of lactic acid bacteria and risk reduction of bladder cancer”. Urologia internationalis, 2002; 68(4):273-280. 23Lidbeck A, et al. “Effect of lactobacillus acidophilus supplements on mutagen excretion in faeces and urine in humans”. Microbial Ecology in Health and Disease, 1992;5(1):59-68. 24Stedman’s Medical Dictionary (27th ed). 2000, Baltimore, MD; Lippincott Williams & Wilkins. 25Grześkowiak L, Endo A, Beasley S, Salminen S. “Microbiota and probiotics in canine and feline welfare”. Anaerobe. 2015;34:14-23. This article has been peer reviewed.
 
Integrative approaches to megaesophagus

Several alternative therapies are attracting attention for successfully treating megaesophagus, either as a sole therapy or part of a larger treatment approach.

Megaesophagus is a disorder of the esophagus in mammals. It’s characterized by esophageal dilatation and an inability of the esophagus to effectively transport food from the throat to the stomach. Megaesophagus occurs predominately in humans and dogs, and is the most common cause of canine regurgitation. Any dog breed can be affected, but certain underlying conditions have breed predilections.1 Experts in general agree that dogs with megaesophagus carry a poor prognosis as they typically die of malnutrition, aspiration pneumonia, or are euthanized because the owners are told there is no hope.2

Pathophysiology of the esophagus

Dysphagia, or disorder of swallowing, is a major sign of esophageal disease. Swallowing is a complex and highly coordinated physical act that can be divided into three phases: oral, pharyngeal and esophageal.3 The oral phase is usually associated with lesions of the oral cavity and tongue, while the pharyngeal phase is associated with pharyngitis and tonsillitis. When considering the esophageal phase, the first and last part may be impeded by failure of the cricopharyngeus muscle to relax during swallowing (achalasia), or increased tension at the lower esophageal sphincter which impedes the flow of food into the stomach.1,3 Segmental or diffuse dysfunction of the body of the esophagus is classified as megaesophagus. It results from atony of the esophageal muscle and is characterized by flaccidity and luminal dilatation. The esophagus is innervated by the vagus nerve; afferent vagal receptors are stimulated by the presence of food and liquid in the pharynx and upper esophagus, causing a swallow reflex and the esophagus to contract.1 The functional lesion may reside in the upper motor neurons of the central swallowing center or in the afferent sensory arm of the reflex controlling peristalsis, which arises in the esophagus.3 Whatever the etiology, the result is failure of the peristaltic propulsion of the food bolus through the lower esophageal sphincter. Retention of food in the esophagus leads to putrefaction and esophagitis in dilated/dependent areas. The volume of the dilated thoracic and cervical esophagus may greatly exceed that of the stomach, with displacement of the intrathoracic trachea and heart ventrally. Common signs animals may present include malnutrition, dehydration, rhinitis and aspiration pneumonia.1,3,4,5

Clinical aspects of megaesophagus

There are two primary categories of megaesophagus -- congenital and acquired. Congenital megaesophagus: In the congenital form of the disease, swallowing dysfunction and regurgitation becomes especially evident with the introduction of solid food.1,3,4 A puppy with congenital megaesophagus characteristically begins to regurgitate at weaning (eight to 12 weeks old) when he is consistently consuming solid food.4 Initially, the puppy regurgitates immediately after food consumption, but as the esophagus dilates, food is held for longer periods before regurgitation. Commonly, the puppy will present with fever, cough and nasal discharge along with poor weight gain as the syndrome becomes complicated by aspiration pneumonia.4 Congenital megaesophagus is primarily associated with heritable anomalies in either neuromuscular innervation or vascular ring anomalies that entrap the esophagus near the heart base. Prognosis for the resolution of congenital megaesophagus in puppies is only 20% to 40%, although there is potential for improvement up to one year of age.1,6 Acquired megaesophagus: Gastrointestinal, endocrine, immune-mediated, neuromuscular, paraneoplastic and toxic disorders have been associated with acquired megaesophagus, with myasthenia gravis being the most common etiology in 25% to 30% of cases.1,5 Affected animals regurgitate (lack of vigorous abdominal contractions, vomitus with PH>5, lacks bilirubin) and have generally lost weight.6 Respiratory signs may predominate with little or no history of regurgitation. Thoracic radiographs reveal air, fluid or food in a dilated esophagus.1,4 Typical treatment involves medical management directed at the etiology, or surgery for vascular ring anomalies. This includes finding a diet that best prevents regurgitation, and this varies between individuals (slurry to more solid). A feeding schedule of small frequent meals from an elevated dish, where the forelimbs are higher than the hindlimbs, along with keeping the dog in this upright position ten to 15 minutes after eating, works best to prevent postprandial regurgitation. The overall prognosis is poor if the underlying etiology cannot be corrected, and many affected animals die from aspiration pneumonia.4

Alternative approaches to megaesophagus

The morbidity and mortality of dogs affected with megaesophagus depends on the degree and nature of the underlying disease (if known), as well as client compliance. Medical management in general is aimed at relieving clinical signs, such as weight loss and respiratory infections secondary to food aspiration. Alternative therapies are increasingly being used to stimulate the esophagus to move more effectively, either as a sole therapy in mild cases or as an adjunct to Western therapeutic management.7-10 Some promising evidence-based clinical studies demonstrate the efficacy of acupoint stimulation on gastrointestinal motility. Studies have focused on two key acupuncture points -- PC-6 and ST-36. Research on PC-6 includes 33 controlled trials (published worldwide as of 1996) for its use for nausea and vomiting, with 27/29 trials showing statistically significant positive results. Stimulating Pericardium 6 (PC-6) in clinical trials produced a significant reduction of perioperative emetic sequelae. ST-36 has been found to have analgesic and spasmolytic effects on the GI tract; it also regulates gastric acidity and has a homeostatic effect in endocrine and metabolic disorders.9,10  Other studies have demonstrated that transcutaneous electrical stimulation (TENS) at LI-4 and SI-3/HT-7 significantly decreased lower esophageal sphincter pressure in humans with achalasia, by creating an increased plasma vasoactive intestinal peptide release. This inhibitory neuropeptide is associated with the relaxation of lower esophageal sphincters.9 Other alternative approaches used successfully in treating megaesophagus include Traditional Chinese Veterinary Medicine (TCVM), homeopathy and laser therapy.

TCVM and acupuncture

In TCVM, megaesophagus is considered a Qi Deficiency, due to the inhibition of directional movement of a tubular organ. It can be also be associated with concurrent Blood or Yin Deficiency with subsequent dryness that fails to lubricate the ingesta. With acquired megaesophagus, an exogenous (i.e. distemper virus, trauma, toxins) or endogenous (i.e. hypothyroidism, hypoadrenocorticism, myasthenia gravis) pernicious influence leading to a localized Wei syndrome (weakness without pain) needs to be considered, and the pattern of imbalance addressed. The primary treatment principles are to tonify global and local Qi, assist directional Qi flow, increase body moisture/fluids, tonify Yin, and nourish and invigorate blood.8 Various acupoint prescriptions for this condition have been presented depending on the TCVM pattern diagnosis as well as results from evidence-based studies. Acupuncture has demonstrated efficacy in the control of vomiting (Stomach Qi rebelling) associated with megaesophagus. In one study on five dogs with idiopathic megaesophagus, a 70% resolution of regurgitation along with increased weight gain was observed when using points PC-6, PC-9, HT-9, ST-36, LI-4, LI-11 and ST-40 with dry needles for ten minutes twice a week for four weeks.8,9,10 Other experts have provided acupoint prescriptions such as LI-4/11, ST-36/41, BL-13/23, PC-6 and HT-9 as beneficial for treating megaesophagus.11 Acupoint selection can also be based on treatment principles and TCVM patterns with Local Points (GB 20/21, TH-17/16, ST-9/10, LI-17/18, CV-22/23) along with Distal Points (LI-4/11, SI-3, LU-7, LIV-3) and Qi Tonifying Points (BL-20/21, BL 23/26, Shen-shu, ST-36, SP-9). Electro-acupuncture is also used with success in this condition, with treatments combining CV-23+CV-22, LI-17+GB-21, BL-14 bilateral, BL-20 bilateral, BL-23 bilateral (20Hz/10 min + 80/120 Hz 10 min).12 Chinese herbal medicine as a component of traditional Chinese Veterinary Medicine is used to address the root of the megaesophagus disease syndrome, Qi deficiency, as well as other imbalances such as Yin and Blood Deficiency. Chinese herbal formulas such as Four Gentlemena (modified Si Jun Zi Tang) for Qi deficiency and/or Happy Eartha (modified Wei Chang He) for rebellious Stomach Qi (regurgitation) in combination with acupuncture can be used successfully to treat megaesophagus. Pharmaceutical studies demonstrating improved gastric emptying and small intestinal motility by inhibiting the dopamine D receptor and 5-HT receptor as well as improvement in overall health in animal subjects has been demonstrated for Si Jun Zi Tang.13, 14, 15 Components of the herbal formula Happy Earth have demonstrated specific and significant effects on the gastrointestinal tract such as inhibition of the vomiting center in the brain and anti-spasmodic effects of the small intestine through modulation of the central nervous system.15, 16, 17

Homeopathy

Homeopathy is an individualized therapeutic approach based on the principles that the same illness creates a different set of clinical signs in different individuals.18 Selection of homeopathic remedies follows the medical principles first espoused by Hippocrates – “Like cures like”, known as the “Law of Similars”. Homeopathic medicine has no formal experimental studies on efficacy associated with treatment of megaesophagus. Clinical evidence shows good results using classical homeopathy to find the “similimum” – the homeopathic medicine that matches the individual animal’s clinical signs associated with the disease condition as well as with general characteristics.

Laser

Low-level laser therapy (LLLT) is a therapeutic modality of photobiostimulation that uses the emission of red and near infrared light wavelengths between 400 nm and 905 nm that are optimally absorbed by mitochondrial chromophores (cytochrome C oxidase). This sets up a cascade of events, including upregulated oxidative phosphorylation and increased ATP production, that modulates the activity of a number of cell types and biological mechanisms. In addition to wavelength and power (measured in watts or miliwatts), various frequencies (ranging from 4 Hz to over 10,000 Hz) are used depending on the tissue type and disease condition being treated. It is imperative to know the power (watts) and wavelength (nm) of the laser device being used in order to apply it appropriately to tissues and not cause harm. Some lasers (Class 4) generate thermal changes to tissues that can be tolerated in musculoskeletal issues, but are contraindicated over endocrine and gonads. The laser system used in the case report on page xx was a Class 2 visible light wavelength (635 nm, 405 nm) frequency specific low power (5 mW, 7.5 mW) laser. The end result is that laser therapy, when used appropriately, with an understanding of the specifications and applications, can provide a non-invasive, pain-free, drug-free and non-surgical treatment for a variety of conditions.

Conclusion

Megaesophagus is a debilitating condition that carries a poor prognosis, whether present congenitally or as an acquired condition in adult dogs. Chronic regurgitation accompanied by aspiration pneumonia leaves an affected animal malnourished and in neverending cycles of severe respiratory distress. Several alternative therapies are beginning to attract attention for successfully treating this condition, either as a sole therapy or a part of a larger integrative medicine approach. As these therapies become more mainstream for the approach of megaesophagus treatment, there is cautious optimism that in some cases the condition could be successfully managed with a good quality of life for the affected animal.

Using acupuncture for megaesophagus

Case #1

A four-month-old intact female five-pound Bichon Frise/Havanese crossbreed was presented to the Integrative Medicine Service with a diagnosis of megaesophagus. The puppy had a history of chronic vomiting after eating (one to two times a day) and a failure to gain weight since weaning. Conventional treatment resulted in no improvement. TCVM with needles and the Chinese herb Happy Earth (modified Wei Chang He) was started. The one-week recheck showed significant clinical improvement, and after three needle treatments and after nine months of Happy Earth, the pup was at a normal weight and asymptomatic. She was still fine at four years of age.

Case #2

A two-year-old male neutered Siberian Husky crossbreed was presented to the emergency and critical care clinic at the Veterinary Teaching Hospital, with a several-week history of vomiting and gagging along with rapidly deteriorating locomotor activity. The dog had been normal prior to a vaccination one week before. With conventional treatment, the dog then developed severe hindquarter weakness and was diagnosed with lower motor neuron disease and referred to the teaching hospital. A diagnosis of presumptive acquired myasthenia gravis of undetermined etiology was made. The dog responded to treatment with a gradual improvement of weakness and decreased regurgitation. Three weeks after the diagnosis, the owner presented her dog to the Integrative Medicine Service for assessment; the goal was to decrease Western medications, which were creating side effects such as ravenous appetite, diarrhea and lethargy, and possible improvement of the megaesophagus. Treatment included dry needle acupuncture and two herbal formulas, Four Gentlemen (to tonify Qi) and concentrated Hindquarter Weakness (to address Qi and Yin Deficiency), with no change in Western drug doses and continued feeding in the Bailey chair. The protein in the dog’s diet was changed from chicken (Hot) to beef (Slight Warm) for a slightly Cooler diet. Two weeks later, at recheck, there was significant improvement with a good appetite, no regurgitation and conscious proprioception normal in one hind leg. Over the next two months, with acupuncture treatment monthly, all Western medications were tapered and then stopped while the dog returned to a normal neurological status and energy level with no regurgitation. He continues to do well at seven months past initial clinical signs.

Using homeopathy for megaesophagus

From Ed DeBeukelaer, MVRCS, author of Homeopathy: What to Expect, Including 101 Cured Cases (12edb3@gmail.com) Two Dalmatian puppies were seen at three weeks of age for milk regurgitation, but were otherwise clinically normal. By five weeks of age, a full diagnostic workup was performed due to increasing dyspnea, yielding a diagnosis of megaesophagus with copious aspiration of milk into the lungs. Phosphorus 30c (tid drops) was started while the owner contemplated whether to continue clinical treatment or euthanize the puppies. The following day, there was a steady improvement in their breathing, accompanied by decreased regurgitation; therefore, treatment was continued. At eight months old, one of the puppies was euthanized due to continued clinical complications. The second puppy is now 2.5 years old, has steadily grown and is taller than her normal littermates. She still regurgitates small amounts of smelly mucus every day but is able to maintain normal nutritional status, with only minor intermittent loss of small amounts of ingesta. She has responded well to the homeopathic medicine Falcon Peregrine (made from Peregrine Falcon) for abdominal enlargement after eating. A year later Ara macau (made from Scarlet Macaw) was prescribed because of her character, mild regurgitation and mild otitis. The ear problem resolved, and she has since taken this remedy every few months in a 30c preparation when the regurgitation increases.

Using laser for megaesophagus

From Janet Gordon Palm, DVM, CVCP (animobilityvet.com) An 11-year-old male neutered Collie presented at New Hope Animal Hospital with evidence of aspiration pneumonia secondary to megaesophagus. The dog had a history of regurgitation and retching multiple times as day for months, and now presented with worsening pneumonia, which had been present for over one week. Radiographs were taken, and a broad-spectrum antibiotic therapy, which included Clavamox and Baytril, was initiated. One week later, the dog presented for recheck. He had not significantly improved and the owner had to go on an international trip. Due to the dog’s deteriorating condition, he was boarded at the veterinary clinic. While at the clinic, the megaesophagus was treated with laser therapy twice daily for two days. On the second day of treatment, the dog was brighter and eating without retching. A total of six treatments were performed over a one-week period. The pneumonia resolved quickly once laser therapy was started, and the dog was relatively cough- and regurgitation-free during the rest of the time he was boarded. The owner was unable to afford the remainder of the recommended 12 total treatments (twice a week for two weeks, followed by once a week for eight sessions). The dog was discharged, and was symptom-free for over five weeks. He then presented with a recurrence of occasional regurgitation, but no further aspiration. Laser treatment was reinstated and the dog was successfully managed with this therapy until euthanasia seven years later, due to unassociated age-related quality of life issues. ______________________________________________________________________

Footnotes

a Veterinary specific patented herbal formula; Jing Tang Herbal, Reddick, FL. USA

References

1KuKanich K. Diagnosis and management of megaesophagus in dogs. In: CVC in Kansas City Proceedings, Aug 01, 2011, Kansas City, Missouri. 2Schachtel, J. Swallowing protocol and early identification of LES achalasia. Abstract; Annual Conference of American College of Veterinary Radiation, Oct 19-22, 2016, Orlando, FL. 3Barker I, Van Dreumel A. The alimentary system. In: Pathology of Domestic Animals 3rd Ed, Jubb K, Kennedy P and Palmer N (eds). Orlando, F; Academic Press 1985:26-27. 4Merck- Aiello S, Mays A (eds).  Anomalies of the Digestive System and Diseases of the Esophagus in Small Animals. In: The Merck Veterinary Manual 8th Ed, Whitehouse Station, NJ; Merck & Co Inc 1998:128, 276-278. 5Mace S, Shelton G, Eddlestone S. Megaesophagus. Web accessed 15Jan2018. Compend Contin Educ Vet 2012 Feb;34(2):E1-E8. 6Willard M. Recognizing and treating esophageal disorders in dogs and cats. Veterinary Medicine 2004, http://veterinarymedicine.dvm360.com/recognizing-and-treating-esophageal-disorders-dogs-and-cats; 15Jan2018 Web access. 7Dodd J. Megaesophagus. Web accessed 15Jan2018; https://drjeandoddspethealthresource.Tumbir 8Clemmons R. Megaesophagus and megacolon. Web access 15Jan2018; dog2doc.com/chi-files/TCVM_Herbs/August_Chi/Megaesophagus_Megacolon.ppt 9Schoen A. Veterinary medical acupuncture for gastrointestinal conditions. In: CVC in San Diego Proceedings, Nov 01, 2009, San Diego, CA. 10Dill S, Bierman N. Acupuncture for Gastrointestinal Disorders. In: Veterinary Acupuncture, Ancient Art to Modern Medicine, Schoen, A (ed). St Louis, MO; Mosby 2001:239-260 11Looney A. Acupuncture and canine disc disease, points for treatment of megaesophagus. Atlantic Veterinary Conference 2001. https://www.vin.com/VINDBPub/SearchPB/Proceedings/PR05000/P00271_IMCO3306.htm; Web access 15Jan2018. 12Xie H, Wedemeyer L, Chrisman C, et al. Practical Guide to Traditional Chinese Veterinary Medicine Small Animal Practice. Chi Institute Press, Reddick, FL, 2014. 13Ye F et al. Pharmacological study of Si Jun Zi decoction of gastrointestinal tract. Shi Zhen Guo Yi Guo Yao. 2005, 16(1):61. (in Chinese) 14Kimura Y et al. Effects of an Atractylodes lancea rhizome extract and a volatile component B-eudesmol on gastrointestinal motility in mice. J Ethnopharacol. 2012, 141(1): 530-536. 15Ma A. Clinical Manual of Chinese Veterinary Herbal Medicine. Gainesville, FL.: Ancient Art Press 2016: 101-102, 208-210. 16Zhao, YJ et al. Effect of rhizome pinelliae on vomiting in minks. Zhongguo Zhong Yao Za Zhi, 205, 30:227-229. 17Watanabe K et al, Pharmacological properties of magnolol and honokiol extracted from magnolia officinalis: central depressant effects. Planta Med. 1983, 49:103-108. 18Khalsa D. Dr Khalsa’s Natural Dog. Irvine, CA: i-5 Press 2015: 115-122.
 
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Integrative ways to optimize mobility in older animals

Integrative medicine has earned a place as first-line treatment for veterinary patients, especially older animals with pain, neurological compromise or debilitating arthritis.

When clients complain that their older animals are refusing to go on walks, that they sleep all the time or have even become aggressive, we need to think about problems centering on mobility and pain. In so doing, however, we should reconsider the “easy fix” of gabapentin, tramadol or non-steroidal anti-inflammatories, and seek to do more to help these patients. Each of the aforementioned medications can cause its own set of problems, such as oversedation, inappetance and organ injury.  Furthermore, they do little to directly treat the causes of mobility impairment, whether due to osteoarthritis, chronic spinal cord injury, myofascial dysfunction or pain.

Issues in aging animals

The problem may extend beyond musculoskeletal and neurologic systems, so a whole patient examination and lifestyle analysis is indicated. Taking the time to gently palpate the myofascia and examine neurologic status yields vital differential diagnostic information about the nature and location of discomfort and/or compromise, without having to force the neck or back into extreme and unnatural ranges of motion. Geriatric animals may need more readily digestible food, anti-aging nutrients, and caloric intake adjustment. Overweight animals are at greater risk of joint disease and inflammation, while underweight individuals may have difficulty procuring, chewing or digesting food. Both states can cause muscles to weaken and strength to further decline. Time may also rob our patients of vision, audition and overall vitality. Perceived cognitive changes such as disorientation, diminished activity, reduced social interactions, behavioral shifts and incontinence may actually stem from undiagnosed pain and neuromuscular impairment. Furthermore, many common geriatric afflictions, such as neoplasia, infections, immune-mediated illness, organ dysfunction and endocrinopathy can also change the way a dog or cat behaves.

Science-based integrative medicine supports movement and reduces pain

After appropriately assessing an animal and identifying the source of his reluctance to rise, walk or otherwise engage in the activities he used to enjoy, the next step is to discuss with the client the pros and cons of conventional and integrative treatment. The latter may involve medical acupuncture, massage, photomedicine (i.e. therapy with laser or light-emitting diodes) or even the cautious inclusion of botanical agents. Each of these techniques, when performed safely and correctly, allows for non-drug and non-surgical options that work on several levels to improve health and restore function.  The aforementioned physical medicine approaches yield overlapping benefits through unique mechanisms of action. Despite their differences, laser, acupuncture and massage all share the common mechanism of neuromodulation. That is, each activates somatic afferent fibers in the periphery; peripheral nerves then deliver impulses to the spinal cord and brain to help normalize central, autonomic and peripheral nervous system function. All three also have the capacity to beneficially impact local tissue, promoting blood flow, reducing pain and working in an anti-inflammatory manner. The versatility and acceptability of these approaches to patients make them suitable for both in-hospital and outpatient care. Healthcare providers can introduce short, supportive treatments throughout the day to help in-patients relax and recover. Motivated clients can learn easy and safe home care techniques involving touch and light-emitting diodes that aid in keeping their animals active and healthy.

1. Acupuncture

Acupuncture incites its somatic afferent stimulation by inducing slight mechanical traction on the tissues near the needle shaft. The metal needle engages with muscle and collagen fibers, leading to a small amount of local tissue deformation capable of causing wide-ranging results. Fascia extending out from the needle begins to relax, and blood flow within the muscle normalizes. Nerve endings and axons in the vicinity issue action potentials and reflexes that cause re-regulation of firing patterns in peripheral, autonomic and central nervous system pathways.

2. Photomedicine

Photomedicine provokes alterations in cellular physiology and neural activity through photonic means. Photoacceptor enzymes within the mitochondria, such as cytochrome c oxidase, absorb photons which then alter the enzyme’s binding patterns with nitric oxide and oxygen. Mitochondrial metabolism increases, as does ATP synthesis. The cavalcade of photochemical events that ensue benefit cellular physiology, intercellular signaling, and tissue repair. What makes laser therapy stand out is this capacity to “kickstart” cellular energy production needed for tissue cleanup and repair.

3. Massage

The mechanical effects of massage activate pressure-sensitive mechanoreceptors in the skin and subcutaneous tissue. Massage can calm or stimulate the nervous system depending on techniques, and it facilitates fluid flow through the interstitium. Signals from treated tissue travel to the spinal cord and brain to normalize nervous system balance within central, peripheral and autonomic networks. The movements of massage encourage the flow of fluids (lymphatic, arterial, venous and interstitial) through the body. This improves the health of not only somatic structures but also visceral function.

The problem of intervertebral disc disease (IVDD)

A common condition affecting older dogs is intervertebral disk disease (IVDD). It causes pain, weakness, muscle tension, inflammation, circulatory compromise and even paralysis.    Clients facing the expense, fear and psychological trauma of having their dogs undergo surgery need to be educated on what non-surgical alternatives can offer based on science and research, along with appropriate anti-inflammatory pharmaceuticals and analgesics, if indicated. In contrast, weeks-long cage confinement, which is a commonly-recommended mandate, has no supportive scientific research and can lead to negative long-term neurologic and orthopedic consequences. Even if a client seeks surgery for a dog with IVDD, the process of removing extruded disc material does little to directly address changes that take place within the spinal cord in the secondary injury phase, which occurs in the days after injury takes place. It may even worsen the inflammatory cytokine responses in the cord and surrounding tissue, and precipitate biochemically-mediated neuronal death and spinal cord inflammation. In contrast, modalities such as photomedicine and acupuncture stimulate recovery by controlling pain, inflammation and edema. They work to promote neural regrowth and functional restoration through stem cell activation and the encouragement of more normalized neural firing patterns. Massage aids the myofascia in relaxing and provides its own form of neuromodulation.

How do you know the treatment is working?

Acupuncture and massage provide immediate feedback through the delivery device; laser does not. A skillful practitioner inserting an acupuncture needle gauges the amount of resistance the needle encounters as it penetrates one or more layers of muscle. This mechanical information conducted through the needle informs the acupuncturist about the state of tone, tension and tenderness in a muscle. Reactions from the patient further advise the acupuncturist about the degree of stimulation taking place within the patient’s nervous system. An experienced massage therapist develops palpatory techniques that convey other types of information. Feeling the tissues respond to touch and the myofascia melt under one’s palms during indirect release techniques provide moment-to-moment messages about how the patient’s body and mind are responding. Laser, like other instrument-driven methods such as ultrasound therapy, limits the amount of tissue engagement by the practitioner unless s/he makes a point of palpating the patient during or soon after treatment. Despite this limitation, all three modalities can fit seamlessly into integrative pain medicine treatment plans. Blending them maximizes the benefits to the patient by multiplying the mechanisms of action at play.

How does the safety of each modality compare?

When practiced by a medical/veterinary professional, acupuncture is one of the safest interventional techniques available. As long as one uses sterile needles and avoids inserting a needle into an organ, the spinal cord, a joint or a major vessel, complications are mild and resolve quickly. Similarly, properly-performed massage is relatively non-injurious as long as pressure is kept reasonable and the practitioner remains cognizant of any patient behavior that indicates discomfort or stress. However, photomedicine with lasers, in contrast to LEDs, may cause problems. Higher-powered laser therapy devices (i.e those in the Class IV category, which deliver >500 mW of power) may cause retinal damage with direct ocular exposure (hence the need for protective and specifically designed laser goggles). Furthermore, the race to produce higher-powered devices in the Class IV category is elevating the number of anecdotal reports of thermal burns and patient pain during the procedure. Clearly, more caution is required for veterinary patients than is often recognized, and geriatric animals with impaired ability to escape a painful treatment, or even sense a thermal burn if they have nerve injury, warrant even more caution and care.

Conclusion

Scientific integrative medicine has earned a place as first-line treatment for veterinary patients across the board, especially for older animals with pain, neurologic compromise or debilitating arthritis. It is time for veterinary medicine to move from a disease-based to a health-supporting paradigm of treatment, and address dysfunction well before it manifests as illness. Performing quick neurologic and gentle myofascial palpation evaluations on patients at every visit will indicate whether and where the animal is developing dysfunction in myofascia, joints or other tissues. We need to stop relying on artificial chemicals to keep animals moving, because their effects are limited and sometimes engender costly and damaging side effects. By working instead through neuromodulation, connective tissue remodeling and photobiomodulation (i.e. acupuncture, massage and photomedicine), the body’s endogenous self-healing mechanisms are engaged, and the patient regains the ability to recover from injury more fully and quickly.

10 homecare tips for clients

  1. Ensure adequate traction in the home (area rugs, carpet runners, non-slip stair treads); consider toe grips or high traction socks or booties for dogs.
  2. Keep nails well-trimmed and delicately trim matted or soiled fur.
  3. Give the animal access to warm or cool surfaces based on his individual needs and preferences; ensure access to fresh, clean air and exercise while avoiding exposure to taxing weather conditions.
  4. Provide clean and appropriately-cushioned surfaces for sleeping and relaxing. Many animals with mobility challenges may prefer firmer bedding that offers much-needed structural support.
  5. Keep animals with elimination problems clean and ensure they have dry bedding.
  6. Help severely impaired animals maintain adequate hydration and nutrition by ensuring they have ready access to food and water.
  7. Consider purchasing a light-emitting diode (LED) device for home treatment of pain and neurologic challenges. Longer exposure to the less intense light offered by LEDs may be safer and more beneficial for some animals than the short bursts of high-powered laser treatments that have become popular in many veterinary practices. Reports of thermal burns and discomfort during treatment are increasing as the hype around high-powered laser units grows.
  8. Encourage daily, appropriate exercise and environmental enrichment. Think about an assistive harness for animals that need help with rising and walking. Purchase a ramp for dogs who enjoy car travel.
  9. Learn simple, safe and supportive massage techniques to improve circulation, digestion, nerve health and pain control.
  10. Examine the pros and cons of botanical medicines such as boswellia, turmeric and cannabidiol to help with pain and inflammation. Consult a veterinarian educated in science-based integrative medicine about options based on facts and research.
 
Digital Infrared Thermal Imaging — Case Studies

These case studies demonstrate how digital infrared thermal imaging can provide an objective assessment of feline and canine patients.

Case study #1

Presentation: Feline patient with a history of a gradual reduction in activity. A physical examination did not localize any sites of discomfort.  Digital infrared thermal images were captured utilizing a Digatherm 640 unit.

Interpretation of the thermal images

Both hind limbs (Figures 1 and 2) exhibited increases within the thermal gradients associated with the stifle joints. The left stifle revealed an increased hyperthermic asymmetry when compared to the right.  Interpretation indicates inflammation within both stifle joints. [gallery columns="2" ids="4042,4043"]   In the right hind limb increases in thermal gradients were noted within the soft tissues radiating out from the stifle joint, particularly over the sartorius and biceps femoralis muscles (Figure 1). Indication of not only an inflammatory process within the joint but an illustration of the strain on the surrounding compensatory soft tissue structures. In the left hind limb areas of hyperthermia were noted directly over the stifle joint and decreased in intensity as they radiate to surrounding soft tissues (Figure 2). Interpretation suggests a lesser amount of inflammation within this joint as the compensatory soft tissue structures surrounding the joint are exhibiting reduced areas of hyperthermic activity when compared to contralateral structures on the right. After this visual representation of their pet’s physiological state to the client, permission was granted to do a radiographic study of both stifles.  This lead to a diagnosis of osteoarthritis. tPEMF therapy was prescribed using the Assisi Loop.  This was done three times per day for one week, once per day the second week, and every other day the third week.

Digital thermal image re-evaluation:

Interpretation of thermal images: After an interpretative analysis of the images: The right stifle experienced a 91% decrease in the hyperthermic activity. Also, there was an increase within the thermal gradients throughout the distal limb. Interpretation: a decrease in inflammation within the original hyperthermic areas and a re-establishment of normal circulation throughout the distal limb. [gallery columns="2" ids="4036,4037"]   The left stifle underwent a 96% decrease within all of the hyperthermic areas observed originally. There was also an increase within the thermal gradients associated within the phalangeal structures. Interpretation: a decrease within the inflammatory state of the stifle joint and the surrounding structures and a re-establishment of the circulatory pattern within the distal limb.

Summary

The treatment plan successfully reduced the inflammatory response within all of the hyperthermic regions and objective measurements are recorded to monitor this patient again in thirty days. Clinically, the patient has regained movement that has not been observed in years.

Case study #2

Presentation: hind limb paralysis. Case contributed by Dominic Gucciardo DVM, CVA; Integrative Veterinary Therapies; Ridge, NY. The initial dorsal thermal image (Figure 1) of the thoracolumbar area showed symmetrical and asymmetrical hypothermic activity throughout numerous vertebral and paravertebral segments. Thermal window of 73-92°F. Interpretation: this correlates to an asymmetrical irritation to the nerve supply to the vasculature in each anatomical region of interest. Electroacupuncture of Bai hui, GV14, GV4, ST36, and BL23 was administered. [gallery ids="4038,4039,4040"]   Eighteen minutes after electroacupuncture. Thermal window of 73-92°F.  Evidence of increases within all thermal gradients throughout image.  This is a visualization and a quantitative measurement of the re-establishment of the circulation within the regions of interest. Twenty-eight minutes after electroacupuncture. The monitoring images (Figures 2 and 3) show progressive increases within the thermal gradients in the areas initially identified as hypothermic.  This indicates a normalization in circulation from re-establishment of neurological function following electroacupuncture.